A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Choice A Reason:

Recording the urinary output at the end of each shift is appropriate action. Furosemide is a loop diuretic that increases urine production. Monitoring urinary output is important to assess the effectiveness of the medication and to ensure that the client is not at risk for dehydration or fluid overload. Recording urinary output at the end of each shift provides a comprehensive overview of the client's renal function and fluid balance.

Choice B Reason:

Checking the urine for ketones every 12 hr is inappropriate action. Checking urine for ketones is not a routine assessment for a client with an indwelling urinary catheter and a prescription for furosemide.

Choice C Reason:

Collecting a 24-hr urine specimen to send to the laboratory is inappropriate. Collecting a 24-hour urine specimen is a more extensive test and is not typically needed for routine monitoring of a client on furosemide.

Choice D Reason:

Measuring the specific gravity of the urine during each shift is incorrect. While monitoring specific gravity can provide information about the concentration of urine, it is not usually required for routine monitoring in this specific situation. Monitoring urinary output is a more practical and clinically relevant approach.

Choice A Reason:

“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.

Choice B Reason:

“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.

Choice C Reason:

“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.

Choice D Reason:

“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.