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
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. Using a thermometer to check the temperature of bath water is a safe practice that helps prevent burns, which is important for clients with PVD who may have reduced sensation.
B. Wearing stockings with elastic tops can restrict blood flow and is generally not recommended for clients with PVD; clients should use non-restrictive stockings instead.
C. Not going barefoot is a good practice to prevent injuries and ulcers, which are risks for clients with PVD.
D. Avoiding crossing the legs is advisable as it helps maintain adequate blood flow and reduces the risk of circulation problems.
Correct Answer is D
Explanation
A. Black cohosh is typically used for menopausal symptoms and does not have a known effect on walking distance in peripheral arterial disease.
B. Echinacea is primarily used to boost the immune system and treat colds, not for vascular conditions.
C. Saw palmetto is commonly used for benign prostatic hyperplasia (BPH) and does not have evidence supporting its use for peripheral arterial disease.
D. Ginkgo biloba has been shown to improve blood flow and may help increase pain-free walking distance in clients with peripheral arterial disease by enhancing peripheral circulation.