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 A
Explanation
A) "Use a raised toilet seat to maintain your hips above your knees.": This statement is appropriate because using a raised toilet seat helps prevent hip flexion beyond 90 degrees, which is crucial for clients recovering from a total hip arthroplasty. Maintaining proper positioning helps reduce the risk of dislocation and promotes safe mobility.
B) "Apply a heating pad to the operative hip to decrease pain.": While heat may provide comfort, it is generally advised to avoid applying heat directly to the surgical site, especially in the immediate postoperative period. Cold therapy is often recommended initially to reduce swelling and pain.
C) "Move your stronger leg first when using a walker.": This statement is incorrect for total hip arthroplasty patients. Typically, they should lead with the operated leg when using a walker to maintain proper alignment and safety during ambulation.
D) "Twist at the waist when standing from a seated position.": This instruction is inappropriate as twisting at the waist can increase the risk of dislocating the hip joint. Clients are generally advised to keep their body aligned and avoid twisting movements during the initial recovery period.
Correct Answer is C
Explanation
A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure
disorder unless there are specific feeding or medication administration needs post-seizure. It is not standard equipment for seizure management.
B) Wrist restraints: While restraints may be used in some situations to prevent injury, they are not routinely placed in a seizure patient's room and could increase the risk of harm during a seizure. It is generally best to ensure a safe environment without restraints.
C) Oral airway: Having an oral airway available in the client's room is essential for managing airway patency during or after a seizure. It can help to maintain an open airway, especially if the client becomes unresponsive or is at risk of aspiration.
D) Tongue blade: Using a tongue blade to hold the mouth open during a seizure is not recommended, as it can cause injury to the client or the nurse. It's a common myth that it should be used to prevent biting the tongue, but doing so can lead to more harm than good