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) 10: A score of 10 on the Glasgow Coma Scale (GCS) indicates a moderate level of impairment in consciousness. This score typically includes a range of responses in eye opening, verbal, and motor responses. Given the client's specific symptoms, this score does not accurately reflect their condition.
B) 13: A GCS score of 13 indicates mild impairment. This score usually requires the ability to open eyes spontaneously, follow commands, and exhibit appropriate verbal responses. Since the client is not opening their eyes and only making incomprehensible sounds, this score is not applicable.
C) 2: A score of 2 on the GCS would imply a severely compromised response, but it would be misleading since the client exhibits decerebrate posturing, which is a significant motor response indicating a level of neurological function. Thus, this score does not adequately represent the client's status.
D) 5: This is the correct score. The GCS includes a score of 1 for no eye opening, 2 for incomprehensible sounds, and 2 for decerebrate posturing. Adding these together (1 for eye opening + 2 for verbal + 2 for motor) results in a total of 5. This score reflects the severe impairment of consciousness and indicates the need for urgent medical evaluation and intervention.
Correct Answer is C
Explanation
A) Administer aspirin: While administering aspirin is important in the management of acute angina to inhibit platelet aggregation, it is not the immediate priority. Aspirin helps prevent further clot formation but does not relieve the acute symptoms of angina.
B) Initiate IV access: Establishing IV access may be necessary for medication administration, but it should not be the first action taken when a client is experiencing acute angina. Immediate relief of chest pain is the priority.
C) Administer nitroglycerin: This is the first action the nurse should take. Nitroglycerin acts quickly to relieve angina by dilating coronary arteries, thus improving blood flow to the heart muscle. Relief of pain and ischemia is the immediate priority.
D) Measure blood pressure: While monitoring vital signs is crucial, especially in a client with cardiac issues, the most urgent intervention in the context of acute angina is pain relief. Blood pressure may be assessed after administering nitroglycerin since it can affect hemodynamics.