A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

A Administer albuterol via nebulizer.

Listen to the lungs fields.

Measure urine output.

Review serum potassium.

Answer and Explanation

The Correct Answer is B

A. Administering albuterol may help if the shortness of breath is due to bronchospasm, but the priority in heart failure is to assess fluid status and respiratory function.
B. Listening to lung fields is crucial to assess for signs of pulmonary edema, which is a common complication in heart failure. This assessment helps determine the effectiveness of the furosemide and whether further intervention is needed.
C. Measuring urine output is important but secondary to assessing respiratory status.
D. Reviewing serum potassium is important but not as urgent as assessing the client's respiratory status.

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Correct Answer is A

Explanation

A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.

B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.

C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.

D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.

A. White blood cell count of 6,000/mm3 (6 x 109/L). B. Decreased blood urea nitrogen. C. Hearing has decreased. D. Reports of photophobia.

Correct Answer is C

Explanation

A. A WBC count within the normal range does not indicate an adverse effect of gentamicin.
B. Gentamicin is more likely to increase BUN levels due to nephrotoxicity rather than decrease them.
C. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, which can lead to hearing loss. Decreased hearing is a significant adverse effect that should be promptly addressed.
D. Photophobia is not a common side effect of gentamicin.

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A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]

Correct Answer is C

Explanation

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