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 A
Explanation
A. Providing a consistent daily routine helps reduce confusion and anxiety in clients with dementia, aiding in their orientation and functioning.
B. Allowing the client to choose activities can lead to frustration or confusion if they are unable to remember options or make decisions, thus requiring structure.
C. Using an overhead loudspeaker may confuse the client and is not effective for communication; it is often better to provide information in person.
D. Posting a written schedule can be helpful but should be combined with a consistent routine for optimal understanding and orientation. Providing a structured environment is crucial for clients with dementia.
Correct Answer is ["B","C","D"]
Explanation
A. Varicose veins are typically associated with venous insufficiency rather than coronary artery disease.
B. Chest pain, or angina, is a common symptom of coronary artery disease due to reduced blood flow to the heart muscle.
C. Palpitations can occur in clients with coronary artery disease as the heart compensates for decreased perfusion.
D. Shortness of breath can result from decreased cardiac output and oxygenation due to coronary artery disease.
E. A heart murmur is not a typical manifestation of coronary artery disease; it is more associated with valvular heart disease.