An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate of 128 beats/minute and irregular, respirations of 38 breaths/minute, blood pressure of 168/100 mm Hg, and oxygen saturation of 90% on room air. Wheezes and crackles are noted throughout bilateral lung fields. An hour after the administration of furosemide 60 mg IV push (IVP), which assessments should the nurse obtain to determine the client's response to treatment? Select all that apply.
Skin elasticity.
Pain scale.
Lung sounds.
Oxygen saturation.
Urinary output.
Correct Answer : C,D,E
Choice A reason: Skin elasticity is not an immediate indicator of the client's response to diuretic treatment. It is more commonly used to assess hydration status and overall skin condition rather than the effectiveness of a diuretic.
Choice B reason: Pain scale is important for assessing the client's comfort level, but it does not directly measure the effectiveness of furosemide in improving respiratory status and reducing fluid overload.
Choice C reason: Lung sounds should be assessed to determine if there is an improvement in the client's respiratory status after the administration of furosemide. Reduction in wheezes and crackles would indicate decreased fluid in the lungs and improved breathing.
Choice D reason: Oxygen saturation is crucial to monitor as it provides information on the client's oxygenation status. An improvement in oxygen saturation levels indicates effective relief of pulmonary congestion and better gas exchange after the diuretic treatment.
Choice E reason: Urinary output is a direct measure of the effectiveness of furosemide, as it promotes diuresis to remove excess fluid from the body. Increased urinary output indicates that the medication is working to reduce fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Pain in the lower legs when walking, also known as intermittent claudication, is a common symptom of PAD but does not indicate an immediate threat to limb viability.
Choice B reason: Black eschar over the ankle ulcer indicates necrotic tissue, which is concerning but not as immediately critical as absent pulses. It does need to be monitored and treated to prevent infection and further complications.
Choice C reason: Absent pedal pulses by Doppler indicate a significant reduction in blood flow to the lower extremities, which can lead to critical limb ischemia and requires immediate intervention to restore perfusion and prevent tissue loss.
Choice D reason: Dependent rubor (redness when the leg is in a dependent position) is a sign of poor arterial circulation but does not require as urgent intervention as absent pedal pulses.
Correct Answer is B
Explanation
Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.
Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.
Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.
Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.
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