An older adult client is receiving digoxin 0.25 mg PO every day, furosemide 40 mg PO twice a day, and potassium chloride 20 mEq PO twice a day. The client remarks, “What a lovely yellow uniform you are wearing today.” The practical nurse (PN) is wearing white. Which action should the PN implement?

Choice A reason: Ankle circumference monitors edema, which mannitol reduces by drawing fluid from tissues. However, this is secondary to urinary output, as mannitol’s primary action is diuresis, increasing urine production to reduce intracranial or intraocular pressure, making edema measurement less critical.

Choice B reason: Heart rate is relevant for overall monitoring but not the primary outcome for mannitol, which acts as an osmotic diuretic. Cardiovascular effects are secondary, and mannitol’s efficacy is better assessed by urine output, which directly reflects its diuretic mechanism.

Choice C reason: Dietary intake is unrelated to mannitol’s therapeutic effect. Mannitol pulls fluid into the bloodstream, increasing urine output, not influenced by diet. Monitoring intake may be relevant for other conditions, but it is not critical for assessing mannitol’s diuretic action.

Choice D reason: Urinary output is the most important outcome, as mannitol, an osmotic diuretic, increases urine production by drawing fluid into the renal tubules, reducing intracranial or intraocular pressure. Adequate output (e.g., >30 mL/hour) confirms efficacy, preventing fluid overload or renal complications.

Choice A reason: Conferring with the charge nurse is unnecessary, as a blood pressure of 120/72 mm Hg is within normal range for a client on maintenance antihypertensive therapy. Maintenance doses prevent hypertension recurrence, and this reading does not indicate a need to alter the schedule.

Choice B reason: Advising the client to report rising blood pressure symptoms is general education, not an action addressing the current situation. The blood pressure is normal, and the maintenance dose is indicated to sustain control, making this choice irrelevant for immediate action.

Choice C reason: Withholding the medication and rechecking in an hour risks blood pressure spikes, as maintenance therapy prevents hypertension. A normal reading of 120/72 mm Hg indicates effective control, and stopping the dose could destabilize the client’s condition, making this choice inappropriate.

Choice D reason: Administering the scheduled antihypertensive dose is correct, as 120/72 mm Hg indicates effective blood pressure control. Maintenance therapy sustains normotension by regulating vascular tone or fluid balance, preventing hypertensive episodes, ensuring cardiovascular stability, and aligning with the prescription’s intent.