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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?

A.

Blood pressure of 80/40 mm/Hg

B.

Oxygen saturation of 95%

C.

Serum sodium level of 140 mEq/L

D.

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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Correct Answer is D

Explanation

A. Wearing gloves when removing food from the freezer is appropriate and helps prevent exposure to cold, which can trigger symptoms of Raynaud's phenomenon.

B. Completing a smoking cessation program is beneficial, as smoking can exacerbate symptoms of Raynaud's.

C. Avoiding stressful situations is advisable since stress can trigger vasoconstriction and exacerbate symptoms

.

D. Keeping the house at a cool temperature is not recommended, as cold environments can provoke Raynaud's symptoms; the client should aim to maintain a warm environment to minimize triggers.

Correct Answer is A

Explanation

A. Managing cholesterol levels is crucial as high cholesterol can lead to plaque buildup in the arteries, increasing the risk of stroke.

B. Using oral contraceptives can actually increase the risk of stroke, especially in women who smoke or have other risk factors.

C. Maintaining a normal blood pressure is essential; elevated blood pressure can lead to increased risk of stroke, not good blood flow.

D. While moderate alcohol consumption may have some benefits, the general recommendation is to limit intake to reduce stroke risk; therefore, stating that up to 3 drinks a day is safe is misleading.

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