A nurse is discussing fibromyalgia with a client who is concerned about developing the disorder. Which finding would the nurse identify as a risk factor for this disease?

Choice A reason:
A respiratory rate of 24/min is slightly elevated, which can be expected in a client with pneumonia due to the body's attempt to increase oxygen intake and carbon dioxide elimination. However, this rate does not directly indicate ineffective airway clearance.

Choice B reason:
A weak, nonproductive cough is a key indicator of ineffective airway clearance. In pneumonia, the presence of secretions in the airways is common, and an effective cough is necessary to clear these secretions. A weak cough that does not produce sputum suggests that the client is unable to clear their airways effectively, which can lead to impaired gas exchange and worsening of symptoms.

Choice C reason:
Pulse oximetry (SpO2) of 90% indicates that the client's oxygen saturation is below the normal range, which is typically between 95-100% for healthy individuals. While this finding is concerning and warrants intervention, it is a result of ineffective airway clearance rather than a direct indicator of it.

Choice D reason:
Shortness of breath with activity is common in clients with pneumonia and can result from various factors, including impaired gas exchange, decreased lung compliance, and increased work of breathing. While it may be associated with ineffective airway clearance, it is not as specific as a weak, nonproductive cough for indicating this particular problem.

Choice A Reason
While maintaining a stable blood pressure is important for a client with hypertension, furosemide is primarily a diuretic, and its therapeutic effect is to reduce fluid overload, not directly to stabilize blood pressure. Therefore, this finding alone does not best indicate the therapeutic effect of furosemide.

Choice B Reason
Clear lungs upon auscultation suggest an improvement in pulmonary edema, which can be associated with fluid overload in conditions such as heart failure. However, for a client with peripheral edema, the primary therapeutic goal of furosemide is to reduce the excess fluid in the extremities, not just the lungs.

Choice C Reason
A decrease in serum potassium is a known side effect of furosemide due to its action on the kidneys, leading to increased excretion of potassium. While it's important to monitor for hypokalemia, a decrease in potassium does not directly indicate the therapeutic effect of reducing edema.

Choice D Reason
An increase in urine output from 30 mL per hour to 100 mL per hour is a direct indication that furosemide is achieving its therapeutic effect. Furosemide is a loop diuretic that increases urine production to help the body eliminate excess fluid, thereby reducing edema associated with conditions like hypertension.