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 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.
Correct Answer is C
Explanation
A) Obtain the client's vital signs: While obtaining vital signs is important after a seizure, it is not the immediate priority during the seizure event. The focus should be on ensuring the client's safety.
B) Lower the client to the floor: Lowering the client to the floor can be a helpful action if the client is standing, but it is not the first step. If the client is already on the floor, this action may not be necessary.
C) Clear items from the client's surrounding area: This is the first action the nurse should take. Clearing the area helps prevent injury to the client during the seizure, ensuring that no objects could potentially cause harm. Safety is the immediate priority during a seizure.
D) Loosen the client's restrictive clothing: While loosening restrictive clothing can be beneficial, it is a secondary action. The primary concern during a seizure is to ensure the client's immediate safety by clearing the surrounding area.