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 C

Explanation

A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.
B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.
C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.
D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.

A. Clamp the catheter for 30 minutes prior to irrigating. B. Slowly irrigate catheter with saline using an infusion pump. C. Use a sterile syringe to irrigate with 20 mL normal saline. D. Power flush with 60 mL to remove mucous obstructions.

Correct Answer is C

Explanation

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.
B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.
C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.
D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

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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 C

Explanation

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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