The nurse obtains a prescription for furosemide 40 mg IV for a client who has pulmonary congestion as the result of fluid volume overload. The nurse assesses the vital signs to be T-98.6, P-110, RR-24 and BP-90/60. What is the most appropriate action at this time?

Withhold the dose and reassess the blood pressure in 30 minutes.

Call the healthcare provider to obtain an order for oral furosemide.

Administer the medication and notify the healthcare provider of the blood pressure.

Administer the dose and continue to monitor the vital signs.

Answer and Explanation

The Correct Answer is C

Choice A reason: Withholding the dose and reassessing the blood pressure in 30 minutes is not the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Delaying the administration of furosemide may worsen the client's condition and increase the risk of complications, such as pulmonary edema or heart failure.

Choice B reason: Calling the healthcare provider to obtain an order for oral furosemide is not the most appropriate action at this time. Oral furosemide is a tablet that is swallowed and absorbed by the digestive system. ¹ It takes longer to act than intravenous (IV) furosemide, which is injected directly into the bloodstream. ¹ The client has pulmonary congestion, which requires immediate treatment to relieve the fluid accumulation in the lungs. Switching to oral furosemide may delay the therapeutic effect and compromise the client's outcome.

Choice C reason: Administering the medication and notifying the healthcare provider of the blood pressure is the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Administering IV furosemide can help remove the excess fluid from the lungs and improve the client's breathing and oxygenation. However, furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ The client already has low blood pressure, which can cause dizziness, fainting, or shock. The nurse should notify the healthcare provider of the blood pressure and monitor the client for any signs of hypotension or adverse reactions.

Choice D reason: Administering the dose and continuing to monitor the vital signs is not the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Administering IV furosemide can help remove the excess fluid from the lungs and improve the client's breathing and oxygenation. However, furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ The client already has low blood pressure, which can cause dizziness, fainting, or shock. The nurse should not only monitor the vital signs, but also notify the healthcare provider of the blood pressure and report any changes or concerns.

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Correct Answer is B

Explanation

Choice A reason: The international normalized ratio (INR) is a measure of the blood's ability to clot. It is not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of INR is 0.8 to 1.2 seconds.

Choice B reason: Hemoglobin is the protein in red blood cells that carries oxygen. It is the main indicator of anemia and the response to iron therapy. The normal range of hemoglobin for adults is 12 to 18 g/dL. A hemoglobin level of 14 g/dL suggests that the patient's anemia has improved with ferrous sulfate therapy.

Choice C reason: Serum iron is the amount of iron in the blood. It is not a reliable indicator of anemia or iron therapy, as it can fluctuate with dietary intake, infection, inflammation, and other factors. The normal range of serum iron for adults is 50 to 170 mcg/dL.

Choice D reason: Platelet count is the number of platelets in the blood. Platelets are involved in blood clotting and wound healing. They are not affected by ferrous sulfate therapy, which is used to treat iron deficiency anemia. The normal range of platelet count for adults is 150,000 to 450,000/mm3.

A. Prepare for endotracheal intubation and ventilatory support. B. Provide continuous sedation for pain relief. C. Initiate cardiac monitoring and assess for reflex bradycardia. D. Maintain IV fluid infusion and assess adequacy of hydration.

Correct Answer is D

Explanation

Choice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.

Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.

Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.

Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.

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The nurse obtains a prescription for furosemide 40 mg IV for a client who has pulmonary congestion as the result of fluid volume overload. The nurse assesses the vital signs to be T-98.6, P-110, RR-24 and BP-90/60. What is the most appropriate action at this time?

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Naxlex Comprehensive Predictor Exams

A patient has recently started ferrous sulfate 500 mg by mouth two times per day for anemia. Which of the following data would indicate to the nurse that the therapy is successful?

Correct Answer is B

Explanation

A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Correct Answer is D

Explanation

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