A patient arrives to the emergency department with crackles audible in the bilateral lungs, and 3+ pitting edema to his lower extremities. The provider orders furosemide 40 mg slow IV push to be given one time. Which of the following assessment findings requires the nurse to hold the medication and contact the provider for further instructions?

Sodium 149 mEq/L

Blood pressure 90/53 mmHg

Client is incontinent of urine

Potassium 53 mEq/L

Answer and Explanation

The Correct Answer is B

A.   Hypernatremia can indicate dehydration or other electrolyte imbalances. Furosemide can further affect electrolyte balance, especially sodium and potassium. However, this sodium level is only slightly elevated and may not necessarily require immediate action regarding furosemide administration.
B.   Furosemide is a diuretic that can further decrease blood pressure due to its effects on fluid volume reduction. Administering it to a patient with already low blood pressure could potentially lead to significant hypotension and compromise perfusion to vital organs.
C.   While incontinence itself may not directly contraindicate furosemide administration, it could indicate underlying issues such as bladder dysfunction or fluid overload that need further evaluation. This finding alone would not necessarily require holding the medication, but it warrants further assessment and consideration in the clinical context.
D.   Normal serum potassium levels typically range from 3.5-5.0 mEq/L. A level of 5.3 mEq/L indicates hyperkalemia (elevated potassium). While this potassium level is mildly elevated, it would not be a reason on its own to hold furosemide. Monitoring potassium levels closely and potentially adjusting potassium

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Correct Answer is C

Explanation

A. While GBS primarily affects peripheral nerves (nerves outside the brain and spinal cord), it does not typically cause direct degeneration of nerves in the brainstem and spinal cord. Therefore, this option is not correct in the context of respiratory distress in GBS.
B. Pleural effusion caused by immobility: Pleural effusion, an accumulation of fluid in the pleural cavity around the lungs, is not a typical complication of GBS. It is more commonly associated with conditions such as heart failure, pneumonia, or malignancy, rather than directly with GBS.
C. In Guillain-Barre Syndrome, demyelination of nerves affects the transmission of signals from the brain to the muscles, including those responsible for respiration. As a result, respiratory muscles may become weak or paralyzed, leading to shallow breathing and respiratory distress.
D. While respiratory distress can occur in some neurological conditions due to autonomic dysfunction or secondary complications, such as aspiration pneumonia, bronchoconstriction and airway edema are not typical manifestations of GBS itself.

A. Limiting fluids during meals B. Influenza vaccination C. Pursed-lip breathing D. Using the tripod position

Correct Answer is B

Explanation

A. This option is not directly related to preventing exacerbations in COPD. While managing fluid intake may be important for individuals with certain cardiovascular or renal conditions, it is not a recognized strategy for preventing COPD exacerbations.
B. Influenza vaccination is highly recommended for individuals with COPD. Respiratory infections, such as influenza (flu), can trigger exacerbations in COPD. By receiving an annual influenza vaccine, the client can reduce the risk of developing influenza-related exacerbations and complications.
C. Pursed-lip breathing is a breathing technique that can help improve ventilation and decrease the work of breathing for individuals with COPD. It can be beneficial during exacerbations or episodes of dyspnea (shortness of breath). While it does not directly prevent exacerbations, it is a useful technique to manage symptoms and potentially reduce the severity of exacerbations.
D. The tripod position, where a person leans forward with hands supported on their knees or another surface, can help COPD patients during exacerbations by allowing better chest expansion and improving breathing mechanics. It can relieve dyspnea and help stabilize breathing. While it does not prevent exacerbations, it is a helpful technique during episodes of increased respiratory distress.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Guillain-Barre Syndrome, and notes that the client's breathing is shallow and the client is short of breath. The nurse understands that that the client's respiratory distress is caused by which of the following?

Correct Answer is C

Explanation

A nurse is discussing treatments and interventions with a client who has chronic obstructive pulmonary disease (COPD). Which of the following would assist in preventing exacerbations?

Correct Answer is B

Explanation

A female client with multiple sclerosis is being treated with prednisone and the immunomodulator drug interferon B-1a to manage the condition. Which finding is the most important for the nurse to report to the provider?

A client on a medical-surgical unit has been diagnosed with Guillain-Barre Syndrome. The nurse understands that in addition to supportive care, which treatment can be used within the first 2 weeks of symptom onset?

The nurse is reviewing the results of the client's echocardiogram and notes that the ejection fraction is 35%. The nurse anticipates that which of the following medications will be ordered to increase the client's cardiac output?

A nurse is providing education to a client who has chronic obstructive pulmonary disease and will begin using fluticasone by metered dose inhaler every 12 hours for maintenance. Which of the following instructions should the nurse include?

A nurse receives report on a client who is diagnosed with thrombotic thrombocytopenic purpura (TTP). Understanding the complications associated with this condition, which assessment is the priority for the nurse to complete for this client?

A nurse is caring for a client who has a diagnosis of immune thrombocytopenic purpura (ITP). When reviewing the results of the client's peripheral blood smear, what would the nurse expect to find?