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 B

Explanation

A. Insulin glargine is a long-acting insulin, and its dose is not based on before-meal blood sugar readings.
B. The client needs to be taught how to self-administer insulin glargine, as it is given subcutaneously once daily, usually at the same time each day.
C. Increasing the dosage in response to ketoacidosis is inappropriate; emergency treatment is required for this condition.
D. Insulin glargine does not have a role in treating severe hypoglycemia; fast-acting glucose or glucagon is used for such situations.

A. Place the vial with the remainder of the medication into a locked drawer. B. Ask another nurse to witness the medication being discarded. C. Withdraw the medication into a syringe and label it with the client's name. D. Throw the vial into the trash in the presence of another nurse.

Correct Answer is B

Explanation

A. Storing the remainder of the medication in a locked drawer is not appropriate for controlled substances that are not fully administered.
B. Lorazepam is a controlled substance, and any unused portion must be disposed of according to hospital policy, typically by discarding it with a witness. The presence of another nurse to witness the discarding process ensures proper documentation and compliance with legal regulations.
C. Withdrawing the medication into a syringe and labeling it is unsafe as it may lead to medication errors or misuse.
D. Simply throwing the vial into the trash, even with another nurse present, does not comply with the proper disposal procedure for controlled substances.

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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

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