The nurse is caring for a client who has right-sided heart failure, and is scheduled to receive the second dose of furosemide Prior to administration of the drug, assessment of the client reveals a marked decrease from 4+ to 1+ ankle edema, neck distention is less than earlier, and the client lost 3 pounds in 24 hours. What action should the nurse take?
Hold the furosemide
Notify the physician
Give the furosemide early
Give the scheduled dose
The Correct Answer is D
A. Hold the furosemide: Withholding the medication would interrupt the effective treatment of the patient's fluid volume excess. The improvement in edema and weight loss indicates that the drug is working as intended, not that it is no longer needed. Stopping the diuretic prematurely can lead to a rebound of congestive symptoms.
B. Notify the physician: The findings represent a positive, expected response to the prescribed medical regimen for heart failure. There is no evidence of an adverse reaction or a change in status that warrants immediate provider notification. Communication should be reserved for clinical deterioration or lack of therapeutic response.
C. Give the furosemide early: Administering the medication before the scheduled time can lead to fluctuations in serum drug levels and increase the risk of electrolyte imbalances. Maintaining the prescribed interval ensures a steady therapeutic effect and safer diuresis. Nurses should adhere to the established dosing schedule for consistency.
D. Give the scheduled dose: The decrease in pitting edema and weight loss demonstrates that the current dose is therapeutic and effective. Continuing the scheduled regimen is necessary to achieve a complete return to dry weight and optimal hemodynamic stability. The nurse should proceed with administration while monitoring for potential hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Dose prescribed: 40 mg
Dose available: 20 mg per tablet
Number of tablets= 40 ÷ 20
= 2 tablets
Correct Answer is ["A","C","D","E","F"]
Explanation
A. Pulse ox of 88% on 3 1pm NC: An oxygen saturation of 88% while receiving 3 liters of oxygen indicates significant impairment in gas exchange. This value is below the standard therapeutic target and suggests worsening pulmonary involvement or ventilation-perfusion mismatch. This finding requires immediate medical evaluation and potential adjustment of respiratory support.
B. Lungs are clear to auscultation: This is a normal finding indicating that, at the time of assessment, there is no audible fluid in the alveoli. While heart failure often causes crackles, clear lungs do not require immediate follow-up as an abnormal finding. It serves as a baseline for monitoring future respiratory changes.
C. + 2 pitting edema of the bilateral hands: Edema in the upper extremities is an atypical finding for standard dependent edema and suggests severe systemic fluid retention. It indicates that the venous backup has progressed beyond the lower extremities to involve more superior vascular beds. This requires investigation into the underlying cause of generalized anasarca.
D. + 2 pitting edema of the ankles and feet: Pitting edema in the lower extremities is a clinical manifestation of systemic venous congestion and fluid volume excess. This finding indicates that the current treatment for peripheral edema is not yet effective. The nurse must monitor this to evaluate the patient's response to diuretic therapy.
E. Blood pressure of 150/82: This reading indicates Stage 2 hypertension, which contributes to increased afterload and exacerbates heart failure. Elevated systemic vascular resistance places additional strain on the myocardium and impairs efficient pumping. Persistent hypertension requires pharmacological management to prevent further cardiac remodeling and damage.
F. Respiratory rate is 24: A rate of 24 breaths per minute is tachypneic and suggests the patient is compensating for hypoxia or decreased lung compliance. This increased work of breathing often precedes more severe respiratory distress in fluid-overloaded patients. It correlates with the low pulse oximetry and necessitates closer clinical observation.
G. Abdomen is soft, non-tender, non-distended: This is a normal physical assessment finding indicating the absence of ascites or organomegaly at this time. It suggests that the fluid volume excess has not yet resulted in significant peritoneal accumulation. No acute nursing or medical follow-up is required for this specific result.
H. Client is alert and oriented x 3: Normal mentation indicates that cerebral perfusion is currently adequate despite the patient's low oxygen saturation. It is a positive sign that the patient is not yet experiencing hypercapnia or severe hypoxia-induced encephalopathy. This baseline is used to monitor for any future neurological decline.
I. Heart rate is 88 bpm: A heart rate of 88 is within the normal adult range of 60 to 100 beats per minute. This indicates that the heart is not currently in a state of compensatory tachycardia to maintain cardiac output. It is a stable finding that does not require immediate clinical follow-up.
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