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 C
Explanation
A) Remind the client of the importance of medication adherence.: While emphasizing medication adherence is important, it does not directly advocate for the client's needs related to self-care at home. It is more of a standard teaching point rather than a specific action to support the client's independence.
B) Tell the client to avoid places where there are large crowds of people.: Advising the client to avoid crowded places is a precaution to prevent infection, but it does not empower the client or help them maintain their self-care abilities. Advocacy involves supporting the client's choices and helping them navigate their circumstances.
C) Initiate a referral for the client to a home health agency.: This action demonstrates client advocacy by actively seeking resources that can provide the client with the support they need to manage their care at home. A home health agency can offer assistance with medication management, monitoring health status, and providing companionship, which aligns with the client's goal of self-care while living alone.
D) Instruct the client to avoid eating raw vegetables.: While this is a valid dietary recommendation for someone with a compromised immune system, it does not specifically advocate for the client’s self-care or independence. It is a preventive measure rather than a supportive action that empowers the client.