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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?

A.

Elevation in blood pressure

B.

Respiratory rate of 24/min

C.

Adventitious breath sounds

D.

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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Correct Answer is D

Explanation

A) Access the catheter using a non-coring needle: A non-coring needle is typically used for accessing implanted ports, not for PICC lines. PICC lines are accessed with a standard IV catheter or a specific type of needle designed for central lines. Therefore, this action is not appropriate for a PICC line.

B) Maintain a continuous IV infusion through the PICC line: While PICC lines can be used for continuous infusions, it is not necessary to maintain a continuous infusion if the client is only receiving intermittent IV bolus antibiotics. The line can remain capped between doses if there are no other infusions required.

C) Change the transparent membrane dressing daily: Transparent dressings for PICC lines should typically be changed every 7 days or if they become damp, soiled, or loose. Daily changes are not required and could increase the risk of infection.

D) Flush the catheter with a 0.9% sodium chloride solution after each use: Flushing the PICC line with a 0.9% sodium chloride solution after each use is the correct action to maintain patency and reduce the risk of clot formation. This is standard practice after administering medications through a central line.

Correct Answer is D

Explanation

A) "I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash." While it is essential to clean areas soiled with body fluids, using alcohol may not be the most effective method for disinfecting surfaces. Standard cleaning protocols typically recommend using bleach solutions or other EPA-registered disinfectants. Moreover, proper disposal of contaminated materials should be done according to local regulations to minimize the risk of exposure.

B) "I will need to take my clothes to the dry cleaners to sterilize them." This statement reflects a misunderstanding of infection control measures. While it is crucial to maintain hygiene, clothes worn by a person with AIDS do not necessarily need to be sterilized by dry cleaning. Regular washing in hot water and detergent is usually sufficient to ensure cleanliness and safety.

C) "I will increase the amount of fresh fruits and vegetables I consume." While a balanced diet is important for overall health, individuals with compromised immune systems, such as those with AIDS, should be cautious about consuming raw fruits and vegetables due to the risk of foodborne illnesses. This statement may indicate a lack of understanding of dietary precautions necessary to protect their health.

D) "I will be sure to wear gloves and wash my hands when I change my cat's litter box." This statement demonstrates an understanding of infection control measures. Wearing gloves helps prevent exposure to potentially harmful pathogens, and washing hands afterward is essential for maintaining hygiene. It reflects the client's awareness of the importance of protecting themselves from infections, which is critical for someone with a weakened immune system.

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