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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. The client's history of hyperlipidemia, because hyperlipidemia can lead to dementia due to blocked neuron communication throughout the body. B. The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia due to the loss of nerve cells in the stomach. C. The client's history of peptic ulcer disease, because peptic ulcer disease can lead to dementia by destroying neuron communication in the stomach. D. The client's history of stroke, because stroke can lead to dementia due to changes in the blood vessels of the brain.

Correct Answer is D

Explanation

A. While hyperlipidemia can contribute to vascular damage, it primarily increases the risk of cardiovascular disease and stroke, rather than directly blocking neuron communication to cause dementia.

B. Peptic ulcer disease is not associated with dementia, and the loss of nerve cells in the stomach does not lead to cognitive decline.

C. Peptic ulcer disease does not cause dementia by impacting neuron communication in the stomach.

D. Vascular dementia is often caused by stroke due to reduced blood flow or damage to the blood vessels in the brain, leading to cognitive decline and memory loss.

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.

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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 D

Explanation

Correct Answer is C

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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Correct Answer is D

Explanation

A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain. The client states that his chest pain is relieved but now he has a headache. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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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?