A nurse is administering furosemide IV bolus to a client who has fluid volume excess.
The nurse should recognize which of the following findings as an indication that the medication has been effective?
Weight loss.
Decreased inflammation.
Increased blood pressure.
Decreased pain.
The Correct Answer is A
The correct answer is A.
Weight loss.
Furosemide is a loop diuretic that is used to treat fluid volume excess by increasing the excretion of water and electrolytes through the kidneys. Weight loss is an indication that the medication has been effective in reducing the excess fluid in the body.
Choice B is wrong because decreased inflammation is not a direct effect of furosemide.
Inflammation is a response to tissue injury or infection, and furosemide does not have any anti-inflammatory properties.
Choice C is wrong because increased blood pressure is not an indication of furosemide effectiveness.
Furosemide lowers blood pressure by reducing the preload and afterload on the heart.
Increased blood pressure may indicate that the dose of furosemide is insufficient or that there are other factors contributing to hypertension.
Choice D is wrong because decreased pain is not an expected outcome of furosemide therapy.
Furosemide does not have any analgesic effects, and pain may be caused by various conditions that are not related to fluid volume excess.
Normal ranges for weight, blood pressure and pain vary depending on the individual patient’s baseline and goals.
However, some general guidelines are:
- Weight: A weight loss of 0.5 to 1 kg per day is considered safe and effective for patients with fluid volume excess.
- Blood pressure: The target blood pressure for most patients with heart failure is less than 130/80 mmHg.
- Pain: The pain level should be assessed using a valid and reliable scale, such as the numeric rating scale or the visual analogue scale, and treated according to the patient’s preference and tolerance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because heart rate 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed, but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
Correct Answer is ["A","B","E"]
Explanation
The correct answer is choicea, b, e.
Choice A rationale:A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.
Choice B rationale:Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.
Choice C rationale:Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.
Choice D rationale:Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.
Choice E rationale:Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.
Choice F rationale:Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.
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