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 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.
Correct Answer is D
Explanation
A) "I should use both hands to recap a needle." This statement reflects unsafe practice. The correct method is to avoid recapping needles whenever possible, and if it is necessary, to use a one-handed technique to minimize the risk of a needlestick injury.
B) "Sterile gloves are required when administering an IM injection." This statement is incorrect because sterile gloves are not typically required for intramuscular (IM) injections. Clean gloves are sufficient, as the injection site does not require a sterile field unless there is a specific reason, such as a compromised immune system.
C) "I should wear a gown to remove linens from a client's bed." While wearing a gown may be necessary in certain situations (such as when there is a risk of exposure to blood or body fluids), it is not universally required for simply removing linens. The decision to wear a gown should be based on the assessment of the risk involved.
D) "I should wear goggles when irrigating a wound." This statement demonstrates an understanding of personal protective equipment use. Goggles or face shields are recommended to protect the eyes from potential splashes of blood or other body fluids during wound irrigation, which is a procedure that can pose a risk of exposure.