A nurse is caring for an older adult client who has heart failure and a prescription for a repeat dose of furosemide 40 mg orally.
Which of the following actions is the nurse's priority?

Remind the client to change positions slowly.

Prepare the client's medication.

Record the client's urinary output.

Review the client's electrolyte levels.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

While reminding the client to change positions slowly is important to prevent orthostatic hypotension, it is not the priority before administering furosemide.

Choice B rationale:

Preparing the client’s medication is an important step, but it should be done after reviewing the client’s electrolyte levels.

Choice C rationale:

Recording the client’s urinary output is important when administering furosemide, a diuretic, but it is not the priority action.

Choice D rationale:

Reviewing the client’s electrolyte levels is crucial before administering furosemide because it can cause electrolyte imbalances, including low potassium levels, which can lead to serious cardiac complications.

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Correct Answer is B

Explanation

Choice A rationale:

Asking the client to demonstrate dose delivery can be part of patient education and helps ensure that the client understands how to use the PCA device. This action does not require intervention.

Choice B rationale:

The nurse administering a PCA dose for the client requires intervention. PCA stands for “Patient-Controlled Analgesia,” meaning that only the patient should administer doses to themselves. This prevents overdosing and ensures that pain medication is administered according to the patient’s needs.

Choice C rationale:

Reassuring the client that the PCA device will not cause an overdose is appropriate because PCA devices are designed with safety measures to prevent overdosing.

Choice D rationale:

Monitoring for oversedation is an important part of care for a client using a PCA device. This action does not require intervention.

A. IV fluid bolus. B. Naloxone. C. Diphenhydramine. D. 15 g of carbohydrates.

Correct Answer is A

Explanation

Choice A rationale:

Administering an IV fluid bolus can help increase blood volume and thus increase blood pressure, which can alleviate symptoms of dizziness and lightheadedness. This is a common side effect of ramipril, especially after the first dose.

Choice B rationale:

Naloxone is an opioid antagonist and is not relevant in this context. It’s used to reverse the effects of opioid overdose, not to treat symptoms associated with antihypertensive medications.

Choice C rationale:

Diphenhydramine is an antihistamine used to treat allergic reactions or insomnia, not symptoms associated with antihypertensive medications.

Choice D rationale:

Administering 15 g of carbohydrates would be appropriate for a hypoglycemic patient, not for a patient experiencing dizziness and lightheadedness due to antihypertensive medication.

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A nurse is caring for an older adult client who has heart failure and a prescription for a repeat dose of furosemide 40 mg orally.Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for an older adult client who has heart failure and a prescription for a repeat dose of furosemide 40 mg orally.
Which of the following actions is the nurse's priority?