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) Administer aspirin: While administering aspirin is important in the management of acute angina to inhibit platelet aggregation, it is not the immediate priority. Aspirin helps prevent further clot formation but does not relieve the acute symptoms of angina.
B) Initiate IV access: Establishing IV access may be necessary for medication administration, but it should not be the first action taken when a client is experiencing acute angina. Immediate relief of chest pain is the priority.
C) Administer nitroglycerin: This is the first action the nurse should take. Nitroglycerin acts quickly to relieve angina by dilating coronary arteries, thus improving blood flow to the heart muscle. Relief of pain and ischemia is the immediate priority.
D) Measure blood pressure: While monitoring vital signs is crucial, especially in a client with cardiac issues, the most urgent intervention in the context of acute angina is pain relief. Blood pressure may be assessed after administering nitroglycerin since it can affect hemodynamics.
Correct Answer is B
Explanation
A) Increased urine output: This finding is more commonly associated with hyperglycemia and diabetic ketoacidosis, where the body attempts to excrete excess glucose through urine. In hypoglycemia, urine output is typically not increased.
B) Cold, clammy skin: This is a classic symptom of hypoglycemia. As blood sugar levels drop, the body releases adrenaline, which can cause sweating and result in cold, clammy skin. This finding directly supports the suspicion of hypoglycemia.
C) Acetone breath: This is associated with diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. The presence of acetone on the breath indicates the breakdown of fat for energy, not a low blood sugar state.
D) Kussmaul respirations: These deep, labored breaths are typically seen in metabolic acidosis, particularly in diabetic ketoacidosis. They are not indicative of hypoglycemia.