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. Computerized tomography angiography (CTA) is commonly used to visualize blood vessels and identify any blockages or abnormalities in blood flow that may have contributed to a TIA.
B. While a complete blood count (CBC) may be ordered as part of the general assessment, it is not specific for diagnosing TIA and does not provide information on cerebrovascular issues.
C. A transesophageal echocardiogram (TEE) is used to assess cardiac function and may be indicated in some stroke cases, but it is not the primary diagnostic test for TIA.
D. Prothrombin time (PT) assesses clotting function but is not specific for diagnosing TIA; it may be ordered for other reasons but is not a primary diagnostic tool in this context.

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 advisable; clients with peripheral venous disease should engage in regular, moderate exercise to improve venous circulation.
B. Massaging the legs is not recommended as it can exacerbate venous insufficiency and potentially lead to complications such as thrombosis.
C. Inspecting the legs daily for changes in color, size, and temperature is crucial for early detection of complications and indicates an understanding of self-monitoring.
D. Keeping the legs in a dependent position can worsen venous pooling; the client should elevate their legs when resting to promote 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

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