The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV. Which parameter would the nurse use to best evaluate if the client is responding to this medication?

Serum sodium level is 135 mEq/L (normal 135-145mEq/L)

Respiratory rate of 16/minute

Blood pressure reading of 120/80

Urine output 120 mL one hour following administration

Answer and Explanation

The Correct Answer is B

A.   Serum sodium level of 135 mEq/L (normal 135-145mEq/L) - Although important, sodium levels do not directly assess the effectiveness of furosemide in relieving fluid overload.
B.   Respiratory rate of 16/minute - A decrease in respiratory rate following the administration of furosemide indicates that the client is improving, as furosemide works to reduce fluid overload and ease breathing.
C.   Blood pressure reading of 120/80 - While blood pressure may be influenced by fluid status, it is not the best indicator for the effectiveness of diuretics in this case.
D.   Urine output 120 mL one hour following administration - While urine output is important, a single hour’s output may not show the full effectiveness of the diuretic, and output can vary depending on the client’s hydration status.

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Correct Answer is D

Explanation

A. A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B. Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C. A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D. Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.

A. Instruct the client to remain quiet and refrain from activity B. Continue to monitor as this may occur with a transvenous pacemaker C. Assess the client's blood pressure and take an apical pulse D. Notify the healthcare provider because the pacemaker is not sensing properly

Correct Answer is D

Explanation

A. Instructing the client to remain quiet may reduce stress or activity but does not address the issue of the pacemaker not sensing properly.
B. Continuing to monitor without addressing the malfunction is inappropriate because this could lead to complications or inappropriate pacing.
C. Assessing blood pressure and pulse is important for patient safety but the priority is addressing the pacemaker's malfunction by notifying the healthcare provider.
D. The pacemaker should sense the client's intrinsic beats to avoid inappropriate pacing. If it is firing on the T wave or at inappropriate times, it indicates a sensing issue that needs to be addressed by the healthcare provider.

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The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV. Which parameter would the nurse use to best evaluate if the client is responding to this medication?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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