A nurse is preparing to administer a Fleets saline enema to an adult client.
Which of the following is an appropriate nursing action?

Choice A rationale

Furosemide is a potent loop diuretic that causes increased excretion of potassium (K+) in the renal tubules, which can lead to hypokalemia (serum K+ less than 3.5 mEq/L). Increasing the intake of potassium-rich foods, such as spinach and kale, is an essential dietary instruction to help mitigate the risk of this potentially dangerous electrolyte imbalance associated with the medication.

Choice B rationale

Furosemide is prescribed, in part, to manage heart failure and hypertension, conditions that require sodium restriction to reduce fluid retention and circulating blood volume. Encouraging increased sodium intake through foods like luncheon meat and chips would directly counteract the therapeutic goals of the diuretic and exacerbate the client's underlying medical conditions.

Choice C rationale

Diuretics, particularly thiazides and loop diuretics like furosemide, are not typically associated with causing hypoglycemia (low blood sugar). In fact, they can sometimes cause or worsen hyperglycemia (high blood sugar) by impairing insulin release and glucose utilization, making increased intake of sweets an inappropriate and potentially harmful recommendation.

Choice D rationale

While maintaining adequate hydration is important, increasing daily water intake to 3500 mL, especially in a client with heart failure and fluid volume overload, is contraindicated and could worsen the fluid overload. Diuretics are given to remove excess fluid, and fluid intake should be monitored and often restricted to prevent exacerbation of symptoms and further cardiac strain.

Choice A rationale

Elevated temperature (fever) is a sign of an infectious or inflammatory process, which typically increases the metabolic demand and often leads to a compensatory increase in heart rate (tachycardia), not a decrease (bradycardia). Bradycardia, defined as a heart rate <60 beats per minute in an adult, may result from various cardiac or non-cardiac causes but is not typically associated with a fever.

Choice B rationale

Fluid volume deficit (hypovolemia) typically stimulates the sympathetic nervous system and the baroreceptor reflex, leading to an increase in heart rate (tachycardia) in an attempt to maintain cardiac output and blood pressure. Severe bradycardia would impair cardiac output and perfusion, but it is not a typical finding or cause of a fluid volume deficit.

Choice C rationale

Lightheadedness, or dizziness, is a common symptom of decreased cerebral perfusion, which occurs when the heart rate is too slow (bradycardia) to maintain adequate cardiac output and blood pressure. Reduced cardiac output directly leads to less oxygenated blood reaching the brain, causing these signs of hypoperfusion.

Choice D rationale

Anxiety activates the sympathetic nervous system, causing the release of epinephrine and norepinephrine. These catecholamines act on beta-adrenergic receptors in the heart, leading to an increase in heart rate (tachycardia). Therefore, anxiety is generally associated with an elevated heart rate, not the decreased heart rate characteristic of bradycardia.