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) Access the catheter using a non-coring needle: A non-coring needle is typically used for accessing implanted ports, not for PICC lines. PICC lines are accessed with a standard IV catheter or a specific type of needle designed for central lines. Therefore, this action is not appropriate for a PICC line.
B) Maintain a continuous IV infusion through the PICC line: While PICC lines can be used for continuous infusions, it is not necessary to maintain a continuous infusion if the client is only receiving intermittent IV bolus antibiotics. The line can remain capped between doses if there are no other infusions required.
C) Change the transparent membrane dressing daily: Transparent dressings for PICC lines should typically be changed every 7 days or if they become damp, soiled, or loose. Daily changes are not required and could increase the risk of infection.
D) Flush the catheter with a 0.9% sodium chloride solution after each use: Flushing the PICC line with a 0.9% sodium chloride solution after each use is the correct action to maintain patency and reduce the risk of clot formation. This is standard practice after administering medications through a central line.
Correct Answer is A
Explanation
A) Place the client's bed at the lowest height: This intervention is essential for safety. Lowering the bed height minimizes the risk of injury from falls, which is particularly important for clients with dementia who may experience disorientation or difficulty with mobility.
B) Request a prescription for a nightly sedative: While managing anxiety and agitation can be important, using sedatives in clients with dementia can lead to increased confusion, falls, and other complications. Non-pharmacological interventions are usually preferred.
C) Assist the client with toileting at least once every 4 hr: While promoting regular toileting is important, the frequency should be tailored to the individual's needs. Clients with dementia may require more frequent assistance based on their understanding and ability to communicate their needs.
D) Turn off all lights in the client's room at night: This could lead to disorientation and fear in clients with dementia. It's usually more beneficial to provide soft lighting to create a calming environment and reduce the risk of falls.