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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

Answer and Explanation

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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A. Monitor the client's vital signs once every hour. B. Elevate the head of the client's bed to a 45° angle. C. Instruct the client not to bend the affected leg. D. Restrict the client's fluid intake.

Correct Answer is C

Explanation

A) Monitor the client's vital signs once every hour: After a cardiac catheterization, it is crucial to monitor vital signs more frequently than every hour. The nurse should assess vital signs every 15 minutes for the first hour, then every 30 minutes for the next two hours, and

then according to the facility's protocol, to quickly identify any complications.

B) Elevate the head of the client's bed to a 45° angle: Elevating the head of the bed to a 45° angle is generally not recommended immediately following cardiac catheterization through the femoral artery. The client should remain flat or with the head elevated no more than 30 degrees to reduce the risk of bleeding from the access site.

C) Instruct the client not to bend the affected leg: This is the most appropriate action. Keeping the affected leg straight is essential to prevent complications such as bleeding or hematoma formation at the catheter insertion site. The client should be instructed to avoid bending or flexing the leg for a specified period, usually several hours post-procedure.

D) Restrict the client's fluid intake: Restricting fluid intake is not necessary after cardiac catheterization. In fact, adequate hydration is often encouraged to help flush the contrast dye from the system and maintain kidney function, provided there are no contraindications.

A. 150 mL of serosanguineous drainage B. 200 mL of brown drainage C. 100 mL of red drainage D. 75 mL of greenish-yellow drainage

Correct Answer is C

Explanation

A) 150 mL of serosanguineous drainage indicates a mixture of serum and blood, which can be expected in the immediate postoperative period. While it should be monitored, this amount is generally not alarming and typically does not require immediate reporting to the provider unless there are other concerning signs.

B) 200 mL of brown drainage may indicate the presence of old blood or bile, depending on the source. While this could warrant further assessment, it is not an immediate cause for concern in the first hour post-surgery, especially if the client is stable and has no other symptoms.

C) 100 mL of red drainage is concerning because bright red blood can indicate active bleeding. This finding is particularly alarming in the first postoperative hour, as it suggests that there may be a significant complication such as a hemorrhage or disruption of the surgical site. Immediate reporting to the provider is necessary to assess the need for intervention.

D) 75 mL of greenish-yellow drainage likely indicates bile or gastric contents. While it should be monitored, especially in the context of the type of surgery performed, this amount alone does not typically necessitate immediate reporting to the provider unless accompanied by other abnormal signs or symptoms.

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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?

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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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?