A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?
"I'm going to include more cantaloupe in my diet."
"I will check my pulse before I take the medication."
"I will try to limit foods that contain salt."
"I'll check my blood pressure so it doesn't get too high."
The Correct Answer is A
Choice A reason: Including more cantaloupe in the diet is a good practice for a client on furosemide therapy. Cantaloupe is high in potassium, and furosemide can cause hypokalemia (low potassium levels) as it is a potent diuretic that increases urine production and the excretion of various electrolytes, including potassium. Therefore, consuming foods rich in potassium can help counteract this potential adverse effect.
Choice B reason: Checking the pulse before taking the medication is a general safety measure but does not directly relate to a specific adverse effect of furosemide. While it's important to monitor heart rate, especially in clients with heart failure, this statement does not reflect an understanding of the adverse effects related to furosemide.
Choice C reason: Trying to limit foods that contain salt is an appropriate action for a client with heart failure but is not directly related to an adverse effect of furosemide. Reducing salt intake can help manage heart failure by preventing fluid retention; however, it does not address the specific adverse effects of furosemide therapy.
Choice D reason: Checking blood pressure to ensure it doesn't get too high is important for clients with heart failure but does not indicate an understanding of the adverse effects of furosemide. Furosemide is used to reduce excess fluid in the body, which can lower blood pressure, not increase it. This statement does not reflect an understanding of furosemide's potential to cause electrolyte imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Tapping the client's facial nerve and noting any facial twitching is not a specific assessment for bacterial meningitis. This action is more related to evaluating facial nerve function and is not typically used to diagnose meningitis.
Choice B reason: Striking the client's patellar tendon with a percussion hammer and noting any increase in response is a test for reflexes, which may or may not be altered in bacterial meningitis. An increased response can be seen in various neurological conditions and is not specific to meningitis.
Choice C reason: Gently elevating the client's head and noting any nuchal rigidity is a key part of the focused assessment for bacterial meningitis. Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and is assessed by gently lifting the head and attempting to move the chin toward the chest. If the client resists due to pain or stiffness, this could indicate nuchal rigidity associated with meningitis.
Choice D reason: Running a tongue blade on the outside of the client's sole and noting any flaring of the toes, known as the Babinski sign, is used to assess for central nervous system lesions and is not specific to meningitis. While it can be part of a neurological assessment, it does not specifically indicate bacterial meningitis.
Correct Answer is B
Explanation
Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.
Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.
Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.
Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.
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