A nurse is assisting in the care of a client on the medical-surgical unit.

Exhibits

Which of the following client findings suggest that the nurse should hold the tube feeding and notify the provider? Select all that apply.

A. "Administer the medication early in the day.": Furosemide is a loop diuretic that increases urine output. Giving it early in the day helps prevent nocturia and sleep disturbances, ensuring the child remains well-rested while still receiving the therapeutic effect of fluid removal.

B. "Restrict foods that are high in potassium in your child's diet.": Furosemide can cause potassium loss, so the child’s diet should include potassium-rich foods rather than restrict them. Adequate potassium intake helps prevent hypokalemia, which can cause muscle weakness, arrhythmias, and other complications.

C. "Anticipate that your child will gain weight rapidly while taking this medication.": Furosemide typically reduces fluid retention, which may lead to weight loss or stabilization, not rapid weight gain. Rapid weight gain would indicate fluid accumulation or worsening heart failure, requiring further evaluation.

D. "Expect your child's urine to appear concentrated and dark yellow.": Furosemide increases urine output and dilutes the urine. Urine is more likely to be pale or clear rather than concentrated and dark yellow unless the child is dehydrated or not adequately hydrated.

A. Notify the primary care provider of the results: Notifying the provider is important for persistent hypoxemia, but the nurse should first ensure the reading is accurate. Immediate action should confirm whether the low saturation reflects true hypoxemia or a measurement error.

B. Document the finding in the medical record: Documentation is part of standard care, but it does not address the potential acute hypoxemia. Recording should occur after verifying the reading and initiating appropriate interventions if needed.

C. Repeat the test on another finger: Pulse oximeter readings can be affected by poor perfusion, nail polish, cold extremities, or device malfunction. Repeating the test on a different finger or site helps confirm the accuracy of the measurement before taking further clinical actions.

D. Consult the respiratory therapist: Referral to a respiratory therapist may be indicated if hypoxemia persists, but it is not the first action. The nurse must first verify the accuracy of the SpO2 reading to determine whether urgent intervention is necessary.