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 128 beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to treatment? (Select all that apply.)

Skin elasticity.

Urinary output.

Oxygen saturation.

Lung sounds.

Pain scale.

Answer and Explanation

Correct Answer : B,C,D

A. Skin elasticity:
Assessing skin elasticity is a measure of hydration status. Improved skin turgor may suggest that the client is responding positively to diuretic therapy by eliminating excess fluid. However, this may not be as immediate or specific as other indicators of response.

B. Urinary output:
Monitoring urinary output is crucial when administering diuretics like furosemide. Increased urine output indicates that the diuretic is promoting the elimination of excess fluid from the body, which is a desired effect in managing heart failure and fluid overload.

C. Oxygen saturation:
Assessing oxygen saturation is important in monitoring respiratory status. Improvement in oxygen saturation levels indicates that the client is responding to interventions aimed at relieving respiratory distress, such as the administration of furosemide.

D. Lung sounds:
Monitoring lung sounds is a key aspect of assessing respiratory function. Reduction in wheezes and crackles suggests that the diuretic is helping to alleviate pulmonary congestion and fluid accumulation in the lungs, contributing to improved respiratory function.

E. Pain scale:
Assessing pain is relevant if the client has reported chest pain or discomfort associated with heart failure. Reduction in pain may indicate improved cardiac function and response to treatment. However, it's important to note that pain assessment may not be as specific to the effects of furosemide as other respiratory and fluid status indicators.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Evaluate the urine for a strong odor.
While evaluating urine for a strong odor can provide some information about a possible urinary tract infection (UTI), it is not the most immediate concern. The priority in this case is to assess for signs of systemic infection, and checking for a strong odor can be done later.

B. Measure her temperature and pulse rate.
This is the correct choice. Measuring temperature and pulse rate is a critical initial step to assess for signs of systemic infection. Fever and an elevated pulse rate can indicate that the infection may have spread beyond the bladder, possibly involving the kidneys.

C. Test her urine for the presence of hematuria.
Testing for hematuria (blood in the urine) is an important diagnostic step for a UTI, but it is not the first priority. Vital sign assessment takes precedence to determine the severity of the condition and the need for urgent intervention.

D. Palpate the right flank for tenderness.
Palpating the right flank for tenderness is a relevant physical assessment to check for kidney involvement, which is important in cases of suspected pyelonephritis. However, assessing vital signs is a more immediate and critical step to determine the severity of the condition.

A. Discuss approaches to chronic pain control with the client. B. Review the client's dietary intake of high-protein foods. C. Notify the healthcare provider of the finding immediately. D. Assess the client's radial pulses and capillary refill time.

Correct Answer is A

Explanation

A. Discuss approaches to chronic pain control with the client:
This is the correct answer. Heberden's nodes are bony enlargements that can occur in osteoarthritis, particularly in the joints of the fingers. These nodes can be associated with pain. Discussing approaches to chronic pain control with the client is an appropriate nursing intervention to address the client's pain and improve quality of life.

B. Review the client's dietary intake of high-protein foods:
Dietary intake of high-protein foods is not directly related to the management of Heberden's nodes in degenerative joint disease. Pain control and joint protection measures are more relevant.

C. Notify the healthcare provider of the finding immediately:
While it's important to communicate significant findings to the healthcare provider, the presence of Heberden's nodes in degenerative joint disease may not require immediate notification unless there are other concerning symptoms or complications.

D. Assess the client's radial pulses and capillary refill time:
Assessing radial pulses and capillary refill time is not directly related to managing Heberden's nodes in degenerative joint disease. These nodes are primarily a result of joint changes in osteoarthritis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

Correct Answer is A

Explanation

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

The nurse is caring for a client with human immunodeficiency virus (HIV) who has developed oral thrush and is experiencing burning and soreness in the mouth. Which intervention should the nurse implement first?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?