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) 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 C
Explanation
A) Monitor the client's vital signs once every hour: After a cardiac catheterization, it is crucial to monitor vital signs more frequently than every hour. The nurse should assess vital signs every 15 minutes for the first hour, then every 30 minutes for the next two hours, and
then according to the facility's protocol, to quickly identify any complications.
B) Elevate the head of the client's bed to a 45° angle: Elevating the head of the bed to a 45° angle is generally not recommended immediately following cardiac catheterization through the femoral artery. The client should remain flat or with the head elevated no more than 30 degrees to reduce the risk of bleeding from the access site.
C) Instruct the client not to bend the affected leg: This is the most appropriate action. Keeping the affected leg straight is essential to prevent complications such as bleeding or hematoma formation at the catheter insertion site. The client should be instructed to avoid bending or flexing the leg for a specified period, usually several hours post-procedure.
D) Restrict the client's fluid intake: Restricting fluid intake is not necessary after cardiac catheterization. In fact, adequate hydration is often encouraged to help flush the contrast dye from the system and maintain kidney function, provided there are no contraindications.