A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide.
For which of the following findings should the nurse withhold the medication?

Oxygen saturation of 95%.

Serum sodium level of 140 mEq/L.

Blood pressure of 80/40 mm Hg.

Serum potassium level of 4.8 mEq/L.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

Choice A: Oxygen saturation of 95% The normal oxygen saturation level is between 95% and 100%. An oxygen saturation of 95% is within the normal range, so the nurse would not need to withhold furosemide for this reason.

Choice B: Serum sodium level of 140 mEq/L The normal serum sodium levels range from 135 to 145 mEq/L. A serum sodium level of 140 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.

Choice C: Blood pressure of 80/40 mm Hg Furosemide is a potent diuretic that can lead to a significant depletion of electrolytes, which may lead to side effects such as muscle cramps and an irregular heartbeat. Low blood pressure (hypotension) is a potential side effect of furosemide. Normal blood pressure for adults is typically around 120/80 mm Hg. A blood pressure reading of 80/40 mm Hg is considerably lower than the normal range, indicating hypotension.

Choice D: Serum potassium level of 4.8 mEq/L The normal serum potassium levels range from 3.6 to 5.2 mEq/L. A serum potassium level of 4.8 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.

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Correct Answer is A

Explanation

The correct answer is choiceA. Heart rate 50/min.

Choice A rationale:

Atenolol is a beta-blocker that can significantly lower heart rate.A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.

Choice B rationale:

A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.

Choice C rationale:

An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.

Choice D rationale:

While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.

A. Low BP and high pulse rate. B. Low BP and low pulse rate. C. High BP and high pulse rate. D. High BP and low pulse rate.

Correct Answer is A

Explanation

Choice A rationale:

Hypovolemic shock is characterized by a decrease in blood volume, leading to low blood pressure and compensatory mechanisms such as a high pulse rate. When the body experiences a significant loss of blood or fluid, it attempts to maintain perfusion to vital organs by increasing the heart rate to ensure an adequate blood supply. Low blood pressure and a high pulse rate are classic signs of hypovolemic shock.

Choice B rationale:

A low BP and low pulse rate are not indicative of hypovolemic shock. Hypovolemic shock is associated with a rapid and weak pulse rate as the body tries to compensate for decreased blood volume. A low pulse rate could suggest other conditions, such as bradycardia, rather than hypovolemic shock.

Choice C rationale:

High BP and high pulse rate are not typical findings in hypovolemic shock. Hypovolemic shock is characterized by low blood pressure and a high pulse rate as the body attempts to compensate for the reduced blood volume. High blood pressure is more commonly associated with conditions like hypertension, not hypovolemic shock.

Choice D rationale:

High BP and low pulse rate are not consistent with the characteristics of hypovolemic shock. As mentioned earlier, hypovolemic shock is marked by low blood pressure and a high pulse rate due to the body's efforts to maintain adequate perfusion. High blood pressure and a low pulse rate may suggest other medical conditions unrelated to hypovolemic shock.

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A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide.
For which of the following findings should the nurse withhold the medication?