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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. Apply ice to the extremity. B. Restrict oral fluids. C. Administer vasodilating medications. D. Monitor platelet levels.

Correct Answer is D

Explanation

A. Applying ice to the extremity is generally not recommended for DVT due to the risk of promoting vasoconstriction and worsening the condition; warm compresses are usually indicated instead.

B. There is no need to restrict oral fluids for a client with DVT unless there are other specific medical reasons; hydration is important.

C. Vasodilating medications are not standard treatment for DVT and may not be appropriate; anticoagulants are typically the primary treatment.

D. Monitoring platelet levels is important in managing DVT, especially when anticoagulants are used, to assess for potential complications such as heparin-induced thrombocytopenia (HIT), making this option correct.

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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 D

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?