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 C
Explanation
A) Respiratory rate 10/min: A respiratory rate of 10 breaths per minute indicates bradypnea, which may be concerning. However, this finding is not directly associated with metoprolol. Metoprolol primarily affects heart rate and blood pressure, making this less relevant in identifying an adverse effect of the medication.
B) Blood pressure 138/76 mm Hg: This blood pressure reading is within the normal range for most individuals. While metoprolol can lower blood pressure, this value does not indicate an adverse effect, as it shows adequate control rather than a concerning reaction.
C) Heart rate 48/min: A heart rate of 48 beats per minute indicates bradycardia, a known adverse effect of beta-blockers like metoprolol. In patients with heart failure, this can lead to insufficient cardiac output and may require intervention. Thus, this finding is critical and should be addressed immediately.
D) Temperature 36.3° C (97.3° F): This temperature is within the normal range and does not indicate an adverse effect related to metoprolol. While monitoring temperature is important, it is not a direct concern regarding the use of this medication.
Correct Answer is A
Explanation
A) Place the client's bed at the lowest height: This intervention is essential for safety. Lowering the bed height minimizes the risk of injury from falls, which is particularly important for clients with dementia who may experience disorientation or difficulty with mobility.
B) Request a prescription for a nightly sedative: While managing anxiety and agitation can be important, using sedatives in clients with dementia can lead to increased confusion, falls, and other complications. Non-pharmacological interventions are usually preferred.
C) Assist the client with toileting at least once every 4 hr: While promoting regular toileting is important, the frequency should be tailored to the individual's needs. Clients with dementia may require more frequent assistance based on their understanding and ability to communicate their needs.
D) Turn off all lights in the client's room at night: This could lead to disorientation and fear in clients with dementia. It's usually more beneficial to provide soft lighting to create a calming environment and reduce the risk of falls.