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) Administer an oral opioid for breakthrough pain: While breakthrough pain can occur, using an oral opioid in conjunction with a PCA device is generally not recommended without specific guidance from a healthcare provider. The PCA device is designed to provide continuous pain relief, and adding another opioid could increase the risk of overdose or respiratory depression.
B) Encourage family members to press the PCA button for the client: Family members should not press the PCA button for the client. PCA is meant for self-administration, allowing patients to control their pain relief within prescribed limits. Allowing others to administer the medication could lead to accidental overdosing and potential respiratory depression.
C) Monitor the client's respiratory status every 4 hr: While monitoring respiratory status is crucial, doing so every 4 hours may not be sufficient, especially right after initiating or adjusting PCA therapy. Respiratory status should be monitored more frequently (e.g., every 1 to 2 hours) in the initial phases to catch any signs of respiratory depression early.
D) Teach the client how to self-medicate using the PCA device: This is the most appropriate action. Educating the client about how to use the PCA device empowers them to manage their pain effectively. Understanding the operation, such as the lockout feature and when they can safely press the button, is vital for ensuring effective pain control while minimizing the risk of overdose.
Correct Answer is A
Explanation
A) Gently elevate the client's head and note any nuchal rigidity: This action is crucial for assessing for meningeal irritation, which is a common sign of bacterial meningitis. Nuchal rigidity refers to stiffness in the neck that makes it difficult for the client to flex their neck forward. This sign, along with other symptoms, can help confirm the suspicion of meningitis.
B) Strike the client's patellar tendon with a percussion hammer and note any increase in response: While assessing deep tendon reflexes can provide information about neurological function, it is not specific to meningitis. Increased reflex response may not
directly indicate meningeal irritation.
C) Tap the client's facial nerve and note any facial twitching: This action is not a standard assessment for bacterial meningitis. Facial twitching could indicate other neurological issues but is not specifically related to meningitis.
D) Run a tongue blade on the outside of the client's sole and note any flaring of the toes: This action describes the Babinski reflex, which is not a typical assessment for meningitis. It may indicate upper motor neuron lesions but does not specifically assess for meningitis.