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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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View Related questions

Correct Answer is A

Explanation

A) "Floss your teeth gently following each meal.": This instruction is appropriate for a client with mucositis. Gentle flossing can help maintain oral hygiene and reduce the risk of infection without causing additional trauma to the already sensitive mucous membranes. It's important to emphasize a gentle approach to minimize discomfort.

B) "Rinse your mouth with hydrogen peroxide.": Rinsing with hydrogen peroxide is not recommended for clients with mucositis, as it can be irritating to the mucous membranes and exacerbate discomfort. Alternatives such as saline or baking soda rinses are typically suggested instead.

C) "Wear your dentures only during meals.": While this may seem practical, clients with mucositis are often advised to avoid dentures altogether if possible, as they can irritate the mucosa. Instead, they should be encouraged to keep their mouth clean and free of irritants.

D) "Brush your teeth for 60 seconds twice daily.": Although maintaining oral hygiene is important, brushing for only 60 seconds may not be sufficient to ensure proper cleaning, especially in the presence of mucositis. It may also be painful, leading to avoidance. A gentler and more thorough approach is often advised, using a soft-bristled toothbrush.

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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