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 C
Explanation
A. A respiratory therapist focuses on breathing and airway management, which is not the primary concern for a client needing strengthening after a stroke.
B. An occupational therapist helps clients with daily living activities and fine motor skills, but the focus on strengthening the affected side is more specific to physical therapy.
C. A physical therapist specializes in developing and implementing exercise programs to strengthen muscles and improve mobility, making this the most appropriate referral for the client's needs.
D. A social worker assists with emotional and social needs but would not focus on physical rehabilitation after a stroke.
Correct Answer is A
Explanation
A. A heart rate of 56/min indicates bradycardia, which can reduce cardiac output and lead to dizziness due to decreased cerebral perfusion.
B. A high temperature is not directly associated with bradycardia; fever typically causes tachycardia.
C. Hypoglycemia does not have a direct relationship with bradycardia; it is more commonly associated with symptoms like sweating, confusion, and tremors.
D. Cigarette smoking typically contributes to conditions like tachycardia and vascular constriction, not bradycardia.