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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?

Blood pressure of 80/40 mm/Hg

Oxygen saturation of 95%

Serum sodium level of 140 mEq/L

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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A. "Your headache is probably a result of anxiety about the chest pain." B. "It sounds as if you are allergic to this medication." C. "A headache is a common adverse effect of this medication, but it will probably occur less often over time." D. "A headache indicates tolerance to the medication."

Correct Answer is C

Explanation

A. The headache is not related to anxiety but is a known side effect of nitroglycerin due to vasodilation.

B. An allergy to nitroglycerin typically presents as a rash or breathing difficulty, not a headache.

C. Nitroglycerin commonly causes headaches due to the dilation of blood vessels in the brain, which usually lessens over time as the body adjusts.

D. A headache does not indicate tolerance to the medication. Tolerance develops when the body becomes less responsive to the medication's effects, which usually involves a reduced effect on chest pain, not the onset of a headache.

A. Muscle strength becomes temporarily stronger. B. A "pill-rolling" tremor appears. C. Electrical charge in the muscle increases in intensity. D. Muscle strength shows no change.

Correct Answer is A

Explanation

A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), confirming the diagnosis of myasthenia gravis.

B. A "pill-rolling" tremor is associated with Parkinson's disease, not myasthenia gravis, and is not relevant to this test.

C. While muscle electrical activity can be assessed in other tests, the Tensilon test specifically evaluates muscle strength changes, not electrical charge intensity.

D. No change in muscle strength would suggest a negative result for myasthenia gravis, indicating that the test did not confirm the diagnosis.

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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?

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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Take full exam for free 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?

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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?