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 D
Explanation
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C. Saw palmetto is mainly used for urinary symptoms related to benign prostatic hyperplasia and does not address the symptoms of peripheral arterial disease.
D. Ginkgo biloba has been shown to improve blood circulation and may help increase pain-free walking distance in clients with peripheral arterial disease, making it the most suitable option.
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.