A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?
“I’m urinating in larger amounts.”
“I have to sleep sitting up.”
“I suck on hard candy for my dry mouth.”
“I’ve lost 3 pounds in the last week.”
The Correct Answer is B
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“I will turn all pot handles toward the back of the stove.” This indicates that the guardian understands how to prevent the toddler from pulling a pot off the stove and getting burned.
Choice B is wrong because a child’s car seat should be rear-facing until the child is at least 2 years old or reaches the maximum height and weight for the seat.
Choice C is wrong because the temperature of the water heater should be set to no higher than 120 degrees to prevent scalding injuries.
Choice D is wrong because drop-side cribs are banned in the United States due to the risk of entrapment and suffocation.
Correct Answer is B
Explanation
Examine your testicles after a warm shower.
This is because a warm shower will relax the scrotum and the muscles holding the testicles, making an exam easier. You should gently roll the scrotum with your fingers to feel the surface of each testicle and check for any lumps, bumps, swelling, hardness or other changes.
Choice A is wrong because you should perform the self-examination every month, not every 3 months.
This will help you notice any changes over time.
Choice C is wrong because you should not palpate both testicles firmly with your fingertips. You should use a gentle touch and avoid squeezing or pressing too hard.
Choice D is wrong because you should not apply a cool compress to the scrotum prior to examination. This will make the scrotum contract and tighten, making an exam more difficult.
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