A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following findings indicates effectiveness of the medication?
Lung sounds clear on auscultation
Bounding radial pulse
Alert and oriented to time, place, and person
Bowel sounds present in four quadrants on auscultation
The Correct Answer is A
A. Lung sounds clear on auscultation: Clear lung sounds indicate that pulmonary congestion has decreased, reflecting effective diuresis from bumetanide. In heart failure, fluid accumulation in the lungs causes crackles or rales, so improvement in breath sounds demonstrates the medication is reducing fluid overload.
B. Bounding radial pulse: A bounding pulse is not an expected effect of bumetanide and may indicate fluid shifts or other cardiovascular changes unrelated to diuresis. While monitoring pulse is important, a bounding pulse does not reflect the drug’s effectiveness in relieving heart failure symptoms.
C. Alert and oriented to time, place, and person: Mental status may improve with correction of severe fluid overload or hypoxia, but being alert and oriented is not a direct measure of bumetanide’s effectiveness. Neurological status alone does not confirm diuretic action or fluid removal.
D. Bowel sounds present in four quadrants on auscultation: Presence of bowel sounds indicates gastrointestinal function is intact but does not provide information about the resolution of heart failure symptoms. While important for overall assessment, it is not a measure of the effectiveness of diuretic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Request a prescription for a nightly sedative.: Sedatives are not a first-line intervention for clients with dementia because they can increase confusion, fall risk, and adverse effects. Nonpharmacologic safety measures are preferred whenever possible.
B. Place the client's bed at the lowest height.: Keeping the bed at its lowest position reduces the risk of injury if the client attempts to get out of bed unassisted. This simple safety measure helps prevent falls, which are a major concern for clients with dementia.
C. Turn off all lights in the client's room at night.: Completely dark environments can increase disorientation and agitation in clients with dementia. Low-level lighting or nightlights is preferable to maintain orientation and safety.
D. Assist the client with toileting at least once every 4 hr.: While regular toileting is important, a 4-hour interval may not meet the client’s individual needs. Toileting schedules should be based on the client’s habits and signs of incontinence to prevent accidents.
Correct Answer is C
Explanation
A. "The best way to treat your cancer is chemotherapy.": This response is directive and does not explore the client’s perspective or provide an opportunity for discussion. It may make the client feel dismissed and does not promote therapeutic communication or informed decision-making.
B. “I have never heard of any holistic treatment that is effective”: This statement invalidates the client’s preference and can damage trust. It focuses on the nurse’s opinion rather than understanding the client’s beliefs, limiting collaborative care and shared decision-making.
C. "Tell me what you know about chemotherapy.": This response encourages the client to share their knowledge and concerns, allowing the nurse to clarify misconceptions and provide education. It fosters an open, therapeutic dialogue and helps the client make an informed choice about treatment options.
D. "You should ask your provider about your plan.": While consulting the provider is important, this response shifts responsibility away from the nurse and does not address the client’s concerns directly. It misses the opportunity to assess understanding and provide immediate support or education.
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