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?

Blood pressure of 80/40 mm/Hg

Oxygen saturation of 95%

Serum sodium level of 140 mEq/L

Serum potassium level of 4.8 mEq/L

Answer and Explanation

The Correct Answer is A

A. A blood pressure of 80/40 mm/Hg indicates hypotension, which is a contraindication for administering furosemide. The medication can further lower blood pressure and increase the risk of adverse effects.
B. An oxygen saturation of 95% is within normal limits and does not indicate a need to withhold furosemide.
C. A serum sodium level of 140 mEq/L is normal and would not warrant withholding the medication.
D. A serum potassium level of 4.8 mEq/L is also normal and safe for furosemide administration, as the medication may cause potassium loss but does not require withholding if the level is within range.

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Correct Answer is A

Explanation

A. Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
B. Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
C. Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
D. Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.

A. “I will decrease my activity to prevent added stress on my legs.” B. “I will need to massage my legs frequently to prevent a buildup of fluid.” C. “I will inspect my legs every day for changes in color, size, and temperature.” D. “I will keep my legs in a dependent position.”

Correct Answer is C

Explanation

A. Decreasing activity is not recommended for peripheral venous disease; clients are encouraged to engage in physical activity to promote circulation and prevent complications.
B. Massaging legs may not be advisable as it could exacerbate swelling and discomfort; instead, elevation is often recommended.
C. Inspecting legs daily for changes is essential for early detection of complications such as skin changes or ulcers, indicating the client understands the importance of monitoring their condition.
D. Keeping legs in a dependent position can worsen venous pooling and swelling; elevation is generally recommended to improve venous return.

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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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Explanation

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