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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Explanation
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C) Wear sterile gloves when collecting the sample: While wearing gloves is important for infection control, non-sterile gloves are typically sufficient for this type of procedure. The focus should be on avoiding contamination of the sample rather than sterility.
D) Collect three samples from a single bowel movement: This statement is incorrect; the standard practice is to collect samples from three different bowel movements on different days, rather than multiple samples from a single event, to increase the reliability of the test results.
Correct Answer is D
Explanation
A) Temperature of 37.9° C (100.2° F): A slight elevation in temperature can be common after surgery and may not indicate a serious issue. It should be monitored, but it is not immediately concerning.
B) Urine output 150 mL over 4 hr: While urine output is an important indicator of kidney function and overall perfusion, this output may still be acceptable depending on the client's overall fluid status and other factors. It does not necessarily require immediate reporting unless there are other concerning symptoms.
C) Bruising around the incisional site: Some bruising can be expected after surgery, particularly with arterial procedures. It should be monitored, but unless there are signs of excessive bleeding or hematoma formation, it is not typically an urgent concern.
D) Pallor in the affected extremity: This finding is critical and should be reported immediately. Pallor could indicate compromised blood flow to the extremity, which could be a sign of complications such as graft occlusion or inadequate perfusion. Prompt intervention may be necessary to prevent serious complications or tissue loss.