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 D

Explanation

Choice A rationale:

Consulting a pharmaceutical sales representative is not the best option. While they are knowledgeable about the medications they promote, their primary role is to market their company’s products, and they may not have comprehensive information about other medications.

Choice B rationale:

While a nursing team member can be a valuable resource, they may not have the specific knowledge about the medication in question. It’s also important to remember that medication information can change frequently, and relying on another person’s knowledge may lead to errors.

Choice C rationale:

The client’s family can provide useful information about how the client has been taking the medication at home, but they are unlikely to have detailed pharmacological knowledge about the medication.

Choice D rationale:

A nursing drug guide is a reliable and up-to-date resource that provides comprehensive information about medications, including indications, contraindications, dosages, potential side effects, and interactions. Therefore, when unfamiliar with a medication, the nurse should consult a nursing drug guide.

A. "Take the medication with a sip of water.” B. "Take one tablet before a strenuous activity.” C. "Take up to four tablets in 15 minutes.” D. "Chew each tablet completely before swallowing.”

Correct Answer is B

Explanation

Choice A rationale:

Sublingual nitroglycerin should be taken without water. The tablet should be placed under the tongue and allowed to dissolve.

Choice B rationale:

It is recommended to take sublingual nitroglycerin before activities that might cause angina.

Choice C rationale:

The maximum recommended dosage is three tablets within 15 minutes, not four.

Choice D rationale:

Sublingual nitroglycerin should not be chewed. It should be allowed to dissolve under the tongue.

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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

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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?