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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Bananas are a good source of potassium, and the client's serum potassium level is low (3.1 mEq/L). Including potassium-rich foods like bananas in the diet can help raise the potassium level and prevent hypokalemia, which is a potential side effect of furosemide (a diuretic).
Choice B rationale:
Cheddar cheese is not a suitable choice for a client with low potassium levels. It is not a significant source of potassium and should not be the primary recommendation for addressing hypokalemia.
Choice C rationale:
Cabbage is not a good choice for increasing potassium intake. While it has some potassium, other fruits and vegetables like bananas are much richer sources of this essential electrolyte.
Choice D rationale:
White rice is not a high-potassium food and should not be the first choice for a client with low potassium levels.
Correct Answer is C
Explanation
Choice A rationale: Tuberculosis treatment with rifampin typically lasts 6 to 9 months. Lifelong therapy is not required for TB, and unnecessary prolonged use increases the risk of drug resistance and hepatotoxicity.
Choice B rationale: Rifampin induces liver enzymes that accelerate the metabolism of oral contraceptives, making them less effective. It does not cause amenorrhea, but it necessitates the use of non-hormonal backup contraception.
Choice C rationale: Rifampin causes a harmless reddish-orange discoloration of urine, sweat, tears, and saliva. This can permanently stain soft contact lenses, so clients are advised to wear eyeglasses during the treatment course.
Choice D rationale: A yellow tint to the skin or sclera indicates jaundice, which is a sign of hepatotoxicity. This is a serious adverse effect rather than an expected reaction and must be reported immediately.
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