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) Wear a surgical mask when providing care to the client.: This is the appropriate action because pertussis (whooping cough) is highly contagious and is transmitted via respiratory droplets. Wearing a surgical mask helps to protect the nurse and other staff from inhaling
these droplets when in close contact with the client.
B) Perform a Mantoux skin test on the client.: The Mantoux skin test is used for detecting tuberculosis exposure, not pertussis. Therefore, this action is not relevant for a client with pertussis and does not address the immediate needs of the situation.
C) Assign the client to a negative-pressure airflow room.: Negative-pressure rooms are typically used for airborne precautions, such as for tuberculosis or COVID-19. Pertussis requires droplet precautions, not airborne precautions, making this option unnecessary.
D) Recommend that the client's family members receive antiviral therapy.: While family members may need prophylactic antibiotics, antiviral therapy is not indicated for pertussis. Instead, they should receive antibiotics like azithromycin or erythromycin to prevent the spread of the disease.
Correct Answer is B
Explanation
A) Decreased heart rate: In thyroid storm, the heart rate typically increases due to elevated levels of thyroid hormones. A decreased heart rate would not be characteristic of this condition.
B) Increased temperature: One of the hallmark signs of thyroid storm is hyperthermia or increased body temperature, often exceeding 101°F (38.3°C). This is due to the heightened metabolic state caused by excess thyroid hormones.
C) Lethargy: While lethargy can occur in other thyroid-related issues, thyroid storm is more commonly associated with hyperactivity and agitation rather than lethargy. Clients may present with restlessness and confusion.
D) Hypotension: In thyroid storm, clients often experience hypertension rather than hypotension. The increased metabolic demands can lead to elevated blood pressure due to increased cardiac output and peripheral vasodilation.