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. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.

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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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL
Calcium	8.0 mg/dL	8.2-10.2 mg/dL:

LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is D

Explanation

Labs

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes the following rhythm of a client on the telemetry unit. Which action should be completed first?

Correct Answer is D

Explanation

The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?

Correct Answer is D

Explanation

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?

Which intervention(s) should the nurse include in the post-operative care of a client following a permanent pacemaker insertion? (SELECT ALL THAT APPLY)

A patient is to receive a continuous infusion of Diltiazem at 5 mg/hr for Atrial fibrillation. The medication is supplied 125 mg of Diltiazem in 125 mL of Iv fluid. At what rate should the nurse set the IV pump? (round to the nearest whole number)

The nurse is providing discharge instructions for the client diagnosed with heart failure. Which information should the nurse provide to assist the client to limit complications and prevent future hospitalizations? (SELECT ALL THAT APPLY).

Labs

The nurse administers atropine 0.5 mg IV to a client. Which action should be performed after the client has received this medication?

The nurse is providing discharge instructions to a client who has had a permanent pacemaker inserted. The information in the chart indicates that the device is a DDD. What will the nurse explain about this pacemaker?