A patient with left-sided heart failure is being treated with enalapril and furosemide. Which assessments should the nurse perform to evaluate the effectiveness of these medications?
Monitor heart rate and rhythm.
Auscultate lung fields and check blood pressure (BP).
Assess for jugular venous distension (JVD).
Check peripheral pulses.
The Correct Answer is B
Choice A reason: Monitoring heart rate and rhythm is important in heart failure management, but it does not directly reflect the effectiveness of enalapril and furosemide, which are primarily used to control blood pressure and reduce fluid overload, respectively.
Choice B reason: Auscultating lung fields can reveal the presence of fluid, indicating pulmonary edema, a common complication of left-sided heart failure. Checking BP is essential as enalapril is an ACE inhibitor that lowers BP, and furosemide can also affect BP through its diuretic effect.
Choice C reason: Assessing for JVD can indicate right-sided heart failure, which may develop secondary to left-sided heart failure. However, it is not the primary assessment for the effectiveness of enalapril and furosemide.
Choice D reason: Checking peripheral pulses is a general assessment and, while important, it does not specifically evaluate the effectiveness of the medications in question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: In sepsis, inflammatory mediators cause vasodilation and increased capillary permeability, leading to fluid leaking out of the vascular space, resulting in hypotension.
Choice B reason: Platelet aggregation and thrombus formation can occur in sepsis but are more related to disseminated intravascular coagulation (DIC) rather than directly causing hypotension.
Choice C reason: Decreased blood glucose and oliguria can be consequences of sepsis but are not the primary pathophysiological processes responsible for hypotension.
Choice D reason: Hypoxemia and anaerobic metabolism may result from the effects of sepsis on the body, including hypotension, but they are not the direct cause of hypotension.
Correct Answer is D
Explanation
Choice A reason: Learning sign language can be beneficial but may not be practical or immediately helpful for the client and spouse dealing with communication issues due to PD.
Choice B reason: Exaggerating the pronunciation of words may help some clients with PD, but it can also be tiring and not effective for all, especially if the client has significant speech difficulties.
Choice C reason: Speaking in a louder tone of voice does not necessarily improve communication with a person who has PD, as the issue often lies with the client's ability to speak, not with hearing.
Choice D reason: Writing can be an effective way for clients with PD to communicate, especially if they have difficulty speaking or being understood. It allows for clear communication without the need for verbal articulation.
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