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 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.

A. Temporary, reversible loss of brain function B. Forgetfulness gradually progressing to disorientation C. Hyper vigilant behaviors D. Sleeping more during the day than nighttime

Correct Answer is B

Explanation

A. Primary dementia is not characterized by temporary or reversible loss of brain function; it typically involves progressive and irreversible changes.
B. Forgetfulness that gradually progresses to disorientation is a common manifestation of primary dementia, indicating cognitive decline.
C. Hyper vigilant behaviors are not typical of dementia; instead, individuals may exhibit confusion or disorientation.
D. Sleeping more during the day than nighttime is not a specific manifestation of primary dementia and could be attributed to other factors, including other medical conditions or medications.

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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

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