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 explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.
B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.
C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.
D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.
Correct Answer is D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needlestick injuries and is not recommended.
B. Placing broken glass in a wastebasket increases the risk of injury to housekeeping staff; it should be disposed of in a puncture-proof container.
C. Recapping needles increases the risk of needlestick injuries and is not recommended unless there are no alternatives available.
D. Placing lancets in a puncture-proof container is the correct procedure for preventing puncture injuries, as it safely contains sharp objects and reduces the risk of accidental needlesticks.
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