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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement indicates a need for further education. After receiving an ICD, clients must refrain from engaging in vigorous physical activities such as contact sports (e.g., football) for a longer period of time to avoid injury or triggering the defibrillator. A longer recovery period is typically recommended.
B. This is correct. Microwaves do not affect the function of an ICD, so it is safe to use one.
C. This is correct. The client should keep their cellphone at least 6 inches away from the ICD to avoid interference with the device.
D. This is correct. Clients may experience a sudden, forceful sensation similar to a kick or blow when the ICD delivers a shock to correct an arrhythmia.
Correct Answer is ["31"]
Explanation
(Volume to be infused (mL) × Drop factor (gtt/mL)) / Time (min).
For the patient prescribed 250 mL of packed red blood cells with a drop factor of 15 gtt/mL over 120 minutes, the calculation would be (250 mL × 15 gtt/mL) / 120 min, which equals 31.25 gtt/min.
Therefore, the nurse should regulate the IV to 31 gtt/min.
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