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
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.
Correct Answer is D
Explanation
A. Standing with feet close together when lifting an object does not provide adequate support or balance, increasing the risk of injury. Proper body mechanics involve keeping feet apart for a stable base of support.
B. Putting weight on the heels when moving an object is not advised. Instead, one should keep the weight distributed over the whole foot for stability.
C. When pushing an object, stepping forward with the front foot (rather than moving it backward) helps to maintain balance and applies proper force.
D. Facing the direction of movement is a correct application of proper body mechanics, as it prevents twisting of the spine, reduces strain on the back, and promotes safe movement.