A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?
Decreased reflexes
Weight gain of 1.4 kg (3b)
Increased urinary output
Jugular vein distention
The Correct Answer is A
A. Decreased reflexes: Loop diuretics can cause electrolyte imbalances, particularly hypokalemia and hypomagnesemia. Hypokalemia can lead to neuromuscular changes, including decreased reflexes, muscle weakness, and potentially life-threatening cardiac arrhythmias. This is an adverse effect that requires prompt assessment and intervention.
B. Weight gain of 1.4 kg (3 lb): Weight gain in heart failure may indicate fluid retention, but a loop diuretic typically promotes diuresis. A small weight gain of 1.4 kg is not immediately indicative of an adverse effect from the medication itself and may reflect other factors, such as fluid shifts or diet.
C. Increased urinary output: Increased urinary output is the intended therapeutic effect of loop diuretics. It indicates that the medication is working to reduce fluid overload rather than an adverse effect.
D. Jugular vein distention: Jugular vein distention is a sign of fluid overload in heart failure. While it may indicate insufficient therapeutic response, it is not a direct adverse effect of the loop diuretic. Monitoring and adjusting therapy may be necessary, but it is not a medication-related complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Transmission of Escherichia coli from undercooked ground beef: This is an example of foodborne transmission, where pathogens are ingested through contaminated food. It does not involve a vector such as an insect or animal.
B. Transmission of giardia from contaminated water: This represents waterborne transmission, occurring when pathogens are ingested through contaminated drinking or recreational water, not via a vector.
C. Transmission of West Nile virus from a mosquito bite: West Nile virus is transmitted through the bite of an infected mosquito, which acts as a vector. This is a classic example of vector-borne transmission, where an organism carries and spreads a pathogen between hosts.
D. Transmission of hepatitis A from a food handler who has the virus: This is an example of direct contact or foodborne transmission, occurring when an infected individual contaminates food. It does not involve a vector to transmit the infection.
Correct Answer is B
Explanation
A. Monitor the client for hypothermia: Hypothermia is not a typical adverse effect of haloperidol. The medication more commonly causes extrapyramidal symptoms and neuroleptic malignant syndrome, which may include hyperthermia rather than hypothermia.
B. Screen the client for tardive dyskinesia: Tardive dyskinesia is a serious, potentially irreversible extrapyramidal side effect associated with long-term use of antipsychotics such as haloperidol. Routine screening using tools like the Abnormal Involuntary Movement Scale (AIMS) is essential to detect early signs and adjust therapy as needed.
C. Check the client's weekly potassium level: Haloperidol does not typically affect potassium levels. Routine electrolyte monitoring is not indicated unless the client has other conditions or is taking medications that affect potassium.
D. Schedule the client for a 24-hr urine collection: A 24-hour urine collection is unrelated to haloperidol therapy. This test is used to assess kidney function or specific metabolic conditions and is not part of routine care for clients taking antipsychotics.
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