A nurse is caring for a child with a congenital heart disease who is prescribed furosemide (Lasix). What is the nurse's priority action before administering this medication?
Assessing the child's respiratory rate.
Checking the child's blood pressure.
Monitoring the child's electrolyte levels.
Determining the child's weight.
The Correct Answer is A
A) The answer is A. Before administering furosemide, it is essential to assess the child's respiratory rate because this medication is a loop diuretic that can lead to fluid and electrolyte imbalances, including hypokalemia. Respiratory rate assessment helps monitor for signs of respiratory distress, especially in clients with heart failure.
B) Incorrect. While monitoring the child's blood pressure is essential, it is not the priority action before administering furosemide. Blood pressure may be affected by the diuretic action of the medication, but respiratory status is more critical to assess initially.
C) Incorrect. Although monitoring electrolyte levels is important when administering furosemide, it is not the priority action. Assessing the child's respiratory rate takes precedence to identify any respiratory distress.
D) Incorrect. Determining the child's weight is relevant in assessing the effectiveness of furosemide therapy. However, it is not the priority action before administering the medication. Respiratory assessment is more critical for immediate intervention.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) This option is incorrect. Infants with congenital heart diseases may have feeding difficulties due to fatigue and inadequate oxygenation, which can affect their appetite and feeding patterns.
B) This option is incorrect. Feeding difficulties in infants with heart defects are common due to their increased energy expenditure and compromised cardiovascular function. These difficulties may require appropriate interventions and ongoing support.
C) Correct answer. Many infants with congenital heart diseases experience fatigue and increased energy expenditure due to their heart's extra workload. This can lead to feeding difficulties, inadequate weight gain, and slower growth.
D) This option is incorrect. Congenital heart diseases can significantly impact feeding patterns in infants, and special attention is required to support their nutritional needs.
Correct Answer is C
Explanation
A) Incorrect. Left-sided heart failure typically presents with symptoms such as pulmonary congestion, shortness of breath, and crackles in the lungs, rather than cyanosis and clubbing.
B) Incorrect. Right-sided heart failure can cause peripheral edema and jugular vein distention, but it does not usually lead to cyanosis and clubbing.
C) The answer is C. Cyanosis and clubbing of the fingers are signs of chronic hypoxia, which can occur in pulmonary hypertension. This condition increases pulmonary vascular resistance and impairs oxygenation, leading to these characteristic symptoms.
D) Incorrect. Peripheral vascular disease primarily affects the arteries and veins in the extremities and is not directly related to cyanosis and clubbing of the fingers.
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