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 B
Explanation
A) Increased urine output: This finding is more commonly associated with hyperglycemia and diabetic ketoacidosis, where the body attempts to excrete excess glucose through urine. In hypoglycemia, urine output is typically not increased.
B) Cold, clammy skin: This is a classic symptom of hypoglycemia. As blood sugar levels drop, the body releases adrenaline, which can cause sweating and result in cold, clammy skin. This finding directly supports the suspicion of hypoglycemia.
C) Acetone breath: This is associated with diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. The presence of acetone on the breath indicates the breakdown of fat for energy, not a low blood sugar state.
D) Kussmaul respirations: These deep, labored breaths are typically seen in metabolic acidosis, particularly in diabetic ketoacidosis. They are not indicative of hypoglycemia.
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.