After administering furosemide 20 mg PO to a client diagnosed with hypertension and peripheral edema, which finding would best indicate that the therapeutic effect of the medication has been achieved?

Blood pressure remains stable at 130/86 mmHg.

Lungs are clear to auscultation.

Serum potassium has decreased from 4.0 to 3.5 mEq/L.

Urine output increases from 30 mL per hour to 100 mL per hour.

Answer and Explanation

The Correct Answer is D

Choice A Reason
While maintaining a stable blood pressure is important for a client with hypertension, furosemide is primarily a diuretic, and its therapeutic effect is to reduce fluid overload, not directly to stabilize blood pressure. Therefore, this finding alone does not best indicate the therapeutic effect of furosemide.

Choice B Reason
Clear lungs upon auscultation suggest an improvement in pulmonary edema, which can be associated with fluid overload in conditions such as heart failure. However, for a client with peripheral edema, the primary therapeutic goal of furosemide is to reduce the excess fluid in the extremities, not just the lungs.

Choice C Reason
A decrease in serum potassium is a known side effect of furosemide due to its action on the kidneys, leading to increased excretion of potassium. While it's important to monitor for hypokalemia, a decrease in potassium does not directly indicate the therapeutic effect of reducing edema.

Choice D Reason
An increase in urine output from 30 mL per hour to 100 mL per hour is a direct indication that furosemide is achieving its therapeutic effect. Furosemide is a loop diuretic that increases urine production to help the body eliminate excess fluid, thereby reducing edema associated with conditions like hypertension.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.

Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.

Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.

Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.

Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.

A. Cyanosis noted in nail beds bilaterally. B. Lungs clear to auscultation. C. Inability to speak in full sentences. D. Pulse oximetry 94-96% on room air.

Correct Answer is ["B","D"]

Explanation

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.

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After administering furosemide 20 mg PO to a client diagnosed with hypertension and peripheral edema, which finding would best indicate that the therapeutic effect of the medication has been achieved?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Correct Answer is ["A","B","D","E"]

Explanation

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Correct Answer is ["B","D"]

Explanation

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