A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
Elevation in blood pressure
Respiratory rate of 24/min
Adventitious breath sounds
Weight loss of 1.8 kg (4 lb) in the past 24 hr
The Correct Answer is D
A) Elevation in blood pressure: An elevation in blood pressure is not an indicator of the effectiveness of furosemide. In fact, effective diuresis would typically lead to a reduction in blood pressure, especially in cases of pulmonary edema related to heart failure.
B) Respiratory rate of 24/min: A respiratory rate of 24/min indicates tachypnea, which is often associated with respiratory distress or ongoing pulmonary congestion. This finding does not suggest that the furosemide is effective; instead, it may indicate that further intervention is needed.
C) Adventitious breath sounds: The presence of adventitious breath sounds, such as wheezing or crackles, suggests ongoing fluid accumulation in the lungs and is not an indicator of effective diuresis. Effective treatment should lead to clearer breath sounds as fluid is removed.
D) Weight loss of 1.8 kg (4 lb) in the past 24 hr: This finding is a strong indicator of the effectiveness of furosemide. A significant weight loss, especially in a client with pulmonary edema, reflects a reduction in fluid overload. Since furosemide works by promoting diuresis, this weight loss suggests that the medication is effectively reducing excess fluid in the body.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A) Fever: While fever can occur in various allergic reactions, it is not a specific indicator of anaphylaxis. It may signal an infection or other inflammatory process rather than an immediate hypersensitivity reaction.
B) Laryngeal edema: This is a hallmark sign of anaphylaxis. It indicates swelling in the throat that can compromise the airway, making it a critical and life-threatening response. Immediate recognition and intervention are necessary to ensure the client's airway remains patent.
C) Hypertension: Although anaphylaxis can sometimes lead to hypotension due to vascular collapse, hypertension is not typically a sign of anaphylaxis. Instead, hypotension is more commonly associated with severe allergic reactions.
D) Arrhythmia: While arrhythmias can occur due to various causes, including stress or electrolyte imbalances, they are not a direct indicator of anaphylaxis. Anaphylaxis primarily presents with respiratory symptoms, skin reactions, and gastrointestinal symptoms, rather than primarily affecting heart rhythm.
Correct Answer is B
Explanation
A) Check pressure points every 12 hr.: This action is insufficient frequency for a client in skeletal traction. Pressure points should be assessed more frequently, ideally every 2 hours, to prevent skin breakdown and complications related to immobility.
B) Provide the client with a trapeze bar.: This is the most appropriate action. A trapeze bar allows the client to assist with repositioning themselves and helps to reduce strain on the muscles and joints, promoting better mobility while in traction.
C) Instruct the client to use their elbows to reposition.: While this might help the client move slightly, using the elbows alone could lead to strain and discomfort. Proper use of a trapeze bar is a better approach to support safe and effective repositioning.
D) Remove the weights before changing the client's bed linens.: Weights should never be removed without a healthcare provider's order as this can disrupt the alignment and effectiveness of the skeletal traction, potentially causing complications.