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) A client who has a headache following a grade 1 concussion: While this client may need monitoring, they are likely stable and do not require constant observation. Therefore, their placement can be further from the nurses' station.
B) A client who has experienced brain death and is awaiting organ procurement: This client may require occasional monitoring, but their condition is stable and less critical in terms of immediate nursing observation compared to those with fluctuating neurological statuses.
C) A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack: A score of 0 indicates no neurological deficits at the time of assessment. This client is stable and does not necessarily require close observation.
D) A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash: A score of 10 indicates altered consciousness and potential risk for deterioration. This client requires closer monitoring and immediate access to nursing care, making it appropriate to assign them to a room closest to the nurses' station.
Correct Answer is D
Explanation
A) Check settings of the CPM machine every 12 hr: This is not frequent enough. The nurse should check the settings of the CPM machine more regularly, typically before each use or every few hours, to ensure the settings are appropriate for the client's therapy.
B) Increase the range of motion rapidly when the CPM machine is used intermittently: This approach is not safe. The range of motion should be increased gradually based on the healthcare provider's orders and the client's tolerance to avoid injury or discomfort.
C) Store the CPM machine on the floor when not in use: Storing the CPM machine on the floor can pose safety hazards, such as tripping or damage to the machine. It should be stored in a safe, designated area when not in use.
D) Turn the CPM machine off while the client is eating: This is an appropriate action. It allows the client to eat comfortably and without obstruction, ensuring they can focus on eating without the machine interfering. Once the client has finished eating, the CPM machine can be turned back on to continue therapy.