The nurse is admitting a 69-year-old male patient with acute heart failure. The physician has ordered furosemide 80 mg IV stat, digoxin 0.25 mg PO, and potassium chloride 20 mEq PO now. Which assessment finding is most indicative of an ineffective response 2 hours after the administration of all the medications?
Pulse oximetry 96%.
Heart rate of 77, regular.
Trace bilateral ankle edema.
Urine output 60 mL.
The Correct Answer is D
The correct answer is d. Urine output 60 mL.
Choice A reason: A pulse oximetry reading of 96% is within normal limits and does not indicate an ineffective response to the medications.
Choice B reason: A heart rate of 77, regular, is also within normal limits and does not suggest an ineffective response.
Choice C reason: Trace bilateral ankle edema may persist even after effective treatment due to residual effects of heart failure.
Choice D reason: A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Petechiae and bruising could be related to low platelet counts or clotting issues, but they are not directly indicated by the provided lab values.
Choice B reason: Jaundice and pruritus are symptoms associated with liver disease but are not specifically indicated by the lab values provided.
Choice C reason: Dyspnea and fatigue could be symptoms of many conditions, including liver disease, but they are not directly indicated by the lab values provided.
Choice D reason: Asterixis, a flapping tremor of the hands, and confusion are signs of hepatic encephalopathy, which can be associated with elevated serum ammonia levels, as indicated by the lab results.
Correct Answer is A
Explanation
Choice A reason: A thyroidectomy, which is the surgical removal of the thyroid gland, directly leads to hypothyroidism because the body can no longer produce thyroid hormones. This client is at the greatest risk of developing hypothyroidism.
Choice B reason: While exposure to certain chemicals in pesticides can be a risk factor for thyroid dysfunction, it does not pose as immediate a risk as the removal of the thyroid gland itself.
Choice C reason: Thyroid nodules can be associated with thyroid dysfunction, but not all nodules result in hypothyroidism, and many are benign and asymptomatic.
Choice D reason: Vomiting secondary to influenza is not directly related to the development of hypothyroidism.
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