A nurse is caring for a patient receiving IV furosemide for peripheral edema who reports feeling dizzy when standing up. The patient's blood pressure is 90/60 mm Hg, potassium level is 3.2 mEq/L, and urine output has increased significantly.
Which nursing action is the priority?
Administer a potassium supplement immediately without notifying the provider.
Implement fall precautions and monitor orthostatic vital signs closely.
Encourage the patient to increase fluid intake to counteract diuresis.
Withhold the next dose of furosemide until the dizziness resolves.
The Correct Answer is B
This question evaluates the management of side effects resulting from loop diuretic therapy. It requires assessing clinical signs of hypovolemia and electrolyte imbalance (normal potassium 3.5 to 5.0 mEq/L) to implement safety interventions that prevent injury while balancing fluid removal and hemodynamic stability.
Choice A rationale
While potassium supplementation is needed for a level of 3.2 mEq/L, administration requires a provider order to ensure safety and correct dosing. Independent administration of medications is outside of nursing scope and could lead to cardiac toxicity.
Choice B rationale
The patient's blood pressure of 90/60 mm Hg and reported dizziness indicate symptomatic orthostatic hypotension. Implementing fall precautions is the immediate priority to ensure patient safety while the nurse continues to monitor hemodynamic status and notifies the provider for further orders.
Choice C rationale
Encouraging increased fluid intake in a patient receiving diuretics for edema is counterproductive to the therapeutic goal of fluid removal. The focus should be on managing the postural hypotension through safety measures and titration rather than reversing the diuretic effect.
Choice D rationale
While withholding the medication might be appropriate given the hypotension and hypokalemia, the nursing priority is first to ensure the patient's immediate safety through fall prevention, followed promptly by reporting the clinical findings to the provider for a definitive medication plan.
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Related Questions
Correct Answer is C
Explanation
This question addresses the safe administration of inhaled medications. It requires applying the principle of bronchodilation to optimize the airway for the subsequent delivery of anti-inflammatory steroids, which ensures maximum drug deposition and efficacy in treating obstructive pulmonary conditions like asthma or COPD.
Choice A rationale
Waiting 2 hours between inhaler doses is not required. The goal of sequential inhalation is to provide immediate, sequential therapeutic effects. Increasing the wait time to 2 hours is clinically unnecessary and reduces the overall efficiency of the patient's medication regimen.
Choice B rationale
Taking the corticosteroid first would be ineffective because the anti-inflammatory medication needs to reach deep into the airways. Without the prior use of a bronchodilator to open the airways, the corticosteroid may be deposited primarily in the oropharynx.
Choice C rationale
Taking the bronchodilator first opens the airways by relaxing the smooth muscles of the bronchioles. This increases the total surface area and airway diameter, allowing the subsequently administered corticosteroid to reach the distal lung tissues for maximum therapeutic anti-inflammatory effect.
Choice D rationale
The order of administration is critical for efficacy. If the corticosteroid is taken without the bronchodilator, the medication delivery is significantly less effective due to the smaller airway diameter, resulting in poor drug penetration and decreased relief for the patient..
Correct Answer is A
Explanation
This question tests clinical recognition of digoxin toxicity, especially in the context of concurrent diuretic use. It requires identifying classic, pathognomonic symptoms of digitalis poisoning, which necessitate immediate nursing intervention to prevent life-threatening cardiac dysrhythmias and associated potential mortality in the clinical setting.
Choice A rationale
Vomiting and visual disturbances, specifically yellow-green halos around lights, are classic signs of digoxin toxicity. Because the patient is also on furosemide, which may induce hypokalemia, the risk for severe arrhythmias is high, requiring urgent clinical assessment.
Choice B rationale
Stomach upset and headache are non-specific symptoms that can occur with many medications. While they should be documented, they are not the specific, hallmark clinical indicators of life-threatening digitalis toxicity that require an emergency level of immediate nursing assessment.
Choice C rationale
Increased urine frequency is the intended therapeutic outcome of furosemide therapy. It indicates that the diuretic is working to reduce fluid overload in the heart failure patient and does not represent an adverse medication event requiring immediate intervention.
Choice D rationale
Night sweats and insomnia are not clinical features associated with digoxin toxicity or furosemide therapy. While they may be indicative of other clinical issues, they do not require the urgent, immediate cardiac assessment that is necessary when assessing for digoxin-related toxicity.
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