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A nurse is collecting data from a client who has heart failure prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

A.

Blood pressure of 80/40 mm/Hg

B.

Oxygen saturation of 95%

C.

Serum sodium level of 140 mEq/L

D.

Serum potassium level of 4.8 mEq/L

Answer and Explanation

The Correct Answer is A

A. A blood pressure of 80/40 mm/Hg indicates hypotension, which is a contraindication for administering furosemide. The medication can further lower blood pressure and increase the risk of adverse effects.  

 

B. An oxygen saturation of 95% is within normal limits and does not indicate a need to withhold furosemide.  

 

C. A serum sodium level of 140 mEq/L is normal and would not warrant withholding the medication.  

 

D. A serum potassium level of 4.8 mEq/L is also normal and safe for furosemide administration, as the medication may cause potassium loss but does not require withholding if the level is within range. 


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Correct Answer is B

Explanation

A. The ascending tracts transmit sensory information to the brain, but they do not process the information; that function is performed in the brain itself.

B. This statement accurately reflects the function of the descending tracts, which carry motor signals from the CNS to the muscles, facilitating voluntary movement.

C. Sensory receptors are located in various tissues throughout the body, including the skin and muscles, but not exclusively in the muscles.

D. Motor neurons are located in the spinal cord and peripheral nervous system, not in the dermal layer of the skin, where sensory receptors reside.

Correct Answer is B

Explanation

A. Using a thermometer to check the temperature of bath water is important for clients with PVD to prevent burns, indicating that this statement reflects understanding.

B. Wearing stockings with elastic tops is not recommended for clients with PVD as they can restrict blood flow and exacerbate symptoms. This indicates a need for further teaching.

C. The statement about not going barefoot is correct, as it helps prevent injury, which is crucial for clients with PVD.

D. Avoiding crossing legs is a proper action to promote circulation and prevent vascular complications, showing the client’s understanding of their condition.

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