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 A
Explanation
A. Dyspnea can indicate heart failure or embolic events resulting from infective endocarditis, making it a serious complication that warrants attention.
B. Fever is a common symptom of infective endocarditis due to the infection but is not a complication; rather, it is part of the disease process.
C. Petechiae are small red or purple spots that can occur with infective endocarditis but are also not considered a complication, rather a manifestation of the condition.
D. A heart murmur may be present due to valvular damage but is not classified as a complication; it is a common finding in infective endocarditis.
Correct Answer is C
Explanation
A. The recommended sodium intake for individuals with hypertension is typically less than 2,300 mg per day, so a goal of 3,000 mg is too high.
B. For individuals with hypertension, it is recommended to limit alcohol consumption to 1 drink per day for women and 2 drinks per day for men, so 3 drinks is excessive.
C. Planning to have potassium blood levels checked when taking thiazide diuretics is important because these medications can lead to hypokalemia (low potassium levels), making this the correct response.
D. Setting a goal body weight within 25% of ideal body weight is not a standard recommendation; weight management should focus on achieving a healthy weight, rather than a specific percentage of ideal body weight.