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A 70-year-old male receiving high-dose IV furosemide for heart failure complains of ringing in his ears and dizziness. His current labs show normal potassium and sodium levels. What is the nurse's most appropriate intervention?

A.

Increase the infusion rate and check the patient's sodium levels again in 2 hours

B.

Administer potassium supplements and continue the infusion

C.

Reassure the patient that the symptoms are temporary and continue monitoring

D.

Stop the furosemide infusion and notify the provider

Answer and Explanation

The Correct Answer is D

A. Increasing the infusion rate may exacerbate the patient's symptoms and does not address the potential toxicity from the furosemide.  

 

B. Normal potassium levels indicate that potassium supplementation is unnecessary and does not address the dizziness and ringing in the ears, which could suggest ototoxicity from furosemide.  

 

C. While reassurance can help, the patient's symptoms indicate a potential adverse reaction to the medication that should not be ignored.  

 

D. Stopping the furosemide infusion and notifying the provider is the most appropriate action due to the risk of ototoxicity and the need for further evaluation of the patient's symptoms.


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Correct Answer is A

Explanation

A. Oliguria, or decreased urine output, is a common finding in hypovolemia due to reduced renal perfusion and decreased blood flow to the kidneys.

B. Hypertension is unlikely in hypovolemia; instead, clients typically exhibit hypotension due to decreased circulating blood volume.

C. Bradycardia is not a typical finding in hypovolemia; instead, tachycardia is more commonly observed as the body compensates for reduced blood volume.

D. Peripheral edema is associated with fluid overload rather than hypovolemia, as a decrease in blood volume usually leads to less fluid accumulation in the tissues.

Correct Answer is B

Explanation

A. Hepatitis is a concern for individuals with HIV, but it is not specifically indicated by a low CD4-T-cell count.

B. A CD4-T-cell count of 150/mm³ indicates severe immunosuppression, making the client highly susceptible to opportunistic infections like tuberculosis, which is common in individuals with HIV.

C. While gonorrhea is a risk for sexually active individuals, it is not specifically related to the low CD4-T-cell count.

D. Chlamydia is also a sexually transmitted infection, but similar to gonorrhea, it is not directly linked to the immunocompromised state indicated by the CD4-T-cell count.

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