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 ["A","B","C","D"]
Explanation
A) Place the client in an upright sitting position: This is the first step because it helps to lower blood pressure by promoting venous return and decreasing the effects of increased sympathetic activity associated with autonomic dysreflexia. Immediate positioning can alleviate acute symptoms and prevent further complications.
B) Confirm that the client's bladder is empty: After ensuring the client is positioned appropriately, the next step is to check for urinary retention, which is a common trigger for autonomic dysreflexia. If the bladder is full, it can exacerbate the condition, so emptying it is crucial.
C)Indicate the risk for autonomic dysreflexia in the client's medical record: While this step is important for ongoing patient care and documentation, it is not an immediate priority during an acute episode of autonomic dysreflexia. Documenting the risk should occur after addressing the client's immediate needs to ensure their safety and well-being
D)Administer an antihypertensive medication intravenously: If the client's blood pressure remains elevated after positioning and emptying the bladder, the next step is to provide pharmacological intervention. Administering an antihypertensive medication can help manage and stabilize the client's blood pressure effectively.
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.