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.
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Correct Answer is D
Explanation
A) Instruct the client to expect tingling in their extremities: Tingling in the extremities is not a common or expected outcome of a lumbar puncture. While some clients may experience mild discomfort, tingling could indicate nerve irritation or other complications that should be assessed.
B) Limit the client's fluid intake: After a lumbar puncture, clients are typically encouraged to increase their fluid intake to help replenish cerebrospinal fluid (CSF) and reduce the risk of headaches. Limiting fluid intake is not appropriate.
C) Measure blood glucose every 2 hr: Routine blood glucose monitoring is not indicated immediately following a lumbar puncture unless there is a specific concern or reason to do so. This action does not directly relate to the care needed post-procedure.
D) Instruct the client to lie flat: Lying flat is often recommended after a lumbar puncture to reduce the risk of post-puncture headache, which can occur due to changes in CSF pressure. This position helps promote healing and minimizes discomfort.
Correct Answer is D
Explanation
A) Avoid administering IV pain medication: While caution is warranted when administering IV medications to a client with petechiae, particularly if thrombocytopenia is suspected, avoiding pain management is not the appropriate action. Pain relief is crucial for the client’s comfort, and IV medications can be safely administered with proper precautions.
B) Determine the client's blood type: Knowing the client's blood type is important for transfusion purposes, especially if there is significant bleeding. However, this action is not the immediate priority in response to the observation of petechiae. The presence of petechiae is more directly related to bleeding risk rather than blood type.
C) Implement airborne precautions: Airborne precautions are necessary for certain infections (e.g., tuberculosis), but they are not indicated for the management of petechiae related to chronic lymphocytic leukemia. The presence of petechiae does not suggest an airborne infection; thus, this action does not address the immediate concern.
D) Institute bleeding precautions: Petechiae indicate a potential for bleeding due to thrombocytopenia, which is common in clients with chronic lymphocytic leukemia. Instituting bleeding precautions, such as using a soft toothbrush, avoiding invasive procedures, and monitoring for additional signs of bleeding, is crucial to prevent serious complications. Therefore, this action is the most appropriate and immediate response.