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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Haemoglobin A1C of 6.2% is the best indication of long-term adherence to the prescribed diabetic regimen. The A1C test measures the average blood glucose levels over the past two to three months. A result of 6.2% indicates that the client has been maintaining good blood glucose control over this period, which reflects adherence to the regimen.

Choice B reason: Fasting plasma glucose of 189 mg/dL (10.49 mmol/L) is higher than the normal range. This result indicates poor short-term blood glucose control and suggests that the client may not be adhering to the prescribed regimen effectively.

Choice C reason: Postprandial plasma glucose of 225 mg/dL (12.49 mmol/L) is also higher than the recommended level for post-meal glucose. This result points to poor post-meal glucose control and suggests that the client may not be following their dietary or medication plan properly.

Choice D reason: High-density lipoprotein (HDL) of 40 mg/dL (1.03 mmol/L) is slightly below the recommended level for HDL cholesterol. While HDL is important for cardiovascular health, it is not a direct measure of blood glucose control or adherence to a diabetic regimen.

A. Take a walk with the client. B. Sit the client in a recliner. C. Administer a sleeping medication. D. Move the client to a locked unit.

Correct Answer is A

Explanation

Choice A reason: Taking a walk with the client is an effective intervention for addressing agitation and restlessness in a client with Alzheimer's disease. Physical activity can help reduce anxiety and agitation, and walking provides a safe and structured way for the client to expend energy while being closely supervised.

Choice B reason: Sitting the client in a recliner may provide temporary comfort, but it does not address the underlying agitation and restlessness. The client may still attempt to leave the room and become more frustrated if their movement is restricted.

Choice C reason: Administering a sleeping medication can have sedative effects, but it should not be the first-line intervention for agitation and restlessness in clients with Alzheimer's disease. Non-pharmacological approaches, such as walking, should be tried first. Sedatives can also increase the risk of falls and other complications.

Choice D reason: Moving the client to a locked unit may be necessary for safety in some cases, but it should not be the initial intervention for agitation and restlessness. The goal is to use less restrictive interventions first to manage the client's behaviour.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best indication that the client is adhering to the prescribed diabetic regimen?

Correct Answer is A

Explanation

During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?

Correct Answer is A

Explanation

A client who is postmenopausal, obese, and is a smoker, has developed an intolerance to fatty foods and believes she is at risk for developing gallbladder problems. Which instruction should the nurse provide to help reduce the client's risk for gallbladder disease?

The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?

An adult client has been admitted to the hospital with asthma exacerbation. Which trigger should the nurse identify as being the most significant cause of this client's asthma complications?

The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?

The nurse calculates the body mass index (BMI) for an adult client who is obese. Which additional assessment finding places the client at high risk for cardiac disease?

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?