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 (3 lb)
Increased urinary output
Jugular vein distention
The Correct Answer is A
Rationale for A: Decreased reflexes can indicate hypokalemia, an adverse effect of loop diuretics. Loop diuretics increase the excretion of potassium, which can lead to low potassium levels, manifesting as muscle weakness and diminished reflexes.
Rationale for B: Weight gain, especially in the context of heart failure, suggests fluid retention rather than an adverse effect of a loop diuretic, which is expected to reduce fluid retention by promoting diuresis.
Rationale for C: Increased urinary output is an expected effect of loop diuretics, as they are used to remove excess fluid. This would not be considered an adverse effect unless it leads to dehydration or electrolyte imbalances.
Rationale for D: Jugular vein distention indicates fluid overload, which would suggest that the diuretic is not effective or that the heart failure is worsening. It is not a direct adverse effect of the medication itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.
B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.
C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.
D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.
Correct Answer is D
Explanation
A. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.
B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.
C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.
D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.
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