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) Move client to a double room. Placing the client in a double room may increase the risk of wandering and confusion, especially if the other occupant has different routines or behaviors. A single room can provide a more controlled and familiar environment, which may help reduce anxiety and the tendency to wander.
B) Encourage participation in activities that provide excessive stimulation. While engagement in activities is beneficial for clients with dementia, providing excessive stimulation can lead to increased confusion and agitation. Activities should be tailored to the client's abilities and interests, promoting engagement without overwhelming them.
C) Use a bed alarm. Implementing a bed alarm is an effective safety measure for clients who wander. It helps alert staff when the client attempts to get out of bed, allowing for timely intervention to prevent wandering and potential injury. This proactive approach supports the client's safety while maintaining their dignity.
D) Use chemical restraints at bedtime. The use of chemical restraints is generally discouraged in managing clients with dementia due to ethical concerns and potential side effects. Alternatives such as environmental modifications and non-pharmacological interventions should be prioritized to ensure the client’s safety and comfort without resorting to medication.
Correct Answer is A
Explanation
A) Slow infusion rate and contact the provider: The client is exhibiting signs of fluid overload, as evidenced by dyspnea and a relatively high blood pressure, along with a significant positive fluid balance (960 mL intake versus 300 mL output). Slowing the infusion rate allows for better management of fluid status, while contacting the provider is crucial to reassess the treatment plan and address potential complications.
B) Change infusion to lactated Ringer's and maintain rate: This action is inappropriate because the underlying issue appears to be fluid overload rather than the type of fluid being administered. Changing the infusion to a different type of fluid does not address the need to manage the current fluid overload situation.
C) Administer prescribed corticosteroids: While corticosteroids may be indicated for certain conditions, in this scenario, the priority is addressing the client's immediate signs of fluid overload rather than administering corticosteroids without further assessment.
D) Lower the head of the bed to semi-Fowler's: While positioning the client to promote comfort and ease breathing is important, the more critical intervention is to address the infusion rate and contact the provider regarding the client’s deteriorating condition. Lowering the head of the bed does not address the underlying problem of fluid overload.