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 A
Explanation
A. Peripheral vascular disease: Intermittent claudication, or pain that occurs during ambulation and is relieved by rest, is a hallmark of arterial insufficiency. Mottling and hairlessness are objective signs of chronic tissue ischemia due to reduced peripheral blood flow. These findings indicate that the arterial supply is failing to meet the metabolic demands of the lower extremity.
B. Coronary artery disease: This condition involves the narrowing of the arteries supplying the heart muscle, typically presenting as chest pain or angina. While it shares the same underlying atherosclerotic process as peripheral vascular disease, it does not directly cause leg mottling or hairlessness. The client’s specific symptoms are localized to the peripheral rather than the cardiac circulation.
C. Right sided heart failure: Right-sided failure primarily manifests as systemic venous congestion, leading to jugular venous distention and dependent edema. It does not typically cause intermittent claudication or the skin changes associated with arterial deprivation. While it affects the lower extremities, it presents with swelling rather than mottling and hair loss.
D. Arterial embolism: An acute embolism usually presents with the "six Ps," including sudden, severe pain, pulselessness, and pallor. The client's report of intermittent pain relieved by rest suggests a chronic, progressive narrowing rather than an acute, total occlusion. An embolism is an emergency that would not typically be relieved simply by resting.
Correct Answer is B
Explanation
A. "Hypertension is the leading cause of death for people your age": While hypertension is a major contributor to mortality, it is often described as a "silent killer" rather than the single leading cause of death. This statement may cause unnecessary alarm without providing specific health education. The focus should be on the specific pathological risks associated with high blood pressure.
B. "Hypertension greatly increases your risk of stroke and heart disease.": Chronic high pressure damages the endothelial lining of the arteries, leading to atherosclerosis and weakened vessel walls. This significantly elevates the probability of ischemic or hemorrhagic strokes and myocardial infarction. Explaining these specific risks helps the patient understand the importance of long-term blood pressure management.
C. "Hypertension if unchecked increases the risk of adult-onset Type 2 diabetes.": Hypertension and diabetes often coexist as part of metabolic syndrome, but high blood pressure does not directly cause diabetes. Diabetes is primarily a disorder of glucose metabolism and insulin resistance. While managing one helps the other, they have distinct primary pathophysiological origins.
D. "Hypertension causes relaxation and dilatation of the arteries which strains the heart": This statement is scientifically incorrect; hypertension is characterized by increased systemic vascular resistance and arterial stiffness. The heart must pump against higher pressure, which leads to ventricular hypertrophy and eventual failure. High blood pressure causes constriction and narrowing, not relaxation, of the vessels.
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