Which of the following interventions is most appropriate for a nurse to perform prior to administering Lasix to a client with heart failure?

Advise the client to avoid highfiber foods with the medication.

Encourage the client to consume a potassium rich diet.

Assess the client’s respiratory rate and oxygen saturation.

Instruct the client to increase fluid intake to prevent dehydration.

Answer and Explanation

The Correct Answer is C

Choice A reason: Advise the client to avoid highfiber foods with the medication is not an appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix does not interact with highfiber foods or affect the digestion directly. Highfiber foods can actually help prevent or treat constipation, which can be a side effect of Lasix. The nurse should encourage the client to eat a balanced and nutritious diet, unless they have any dietary restrictions or allergies.

Choice B reason: Encourage the client to consume a potassium rich diet is not an appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix can also cause the loss of potassium in the urine, which can lead to hypokalemia, a condition that causes muscle weakness, cramps, arrhythmias, or cardiac arrest. The nurse should monitor the serum potassium level and administer potassium supplements or potassiumsparing diuretics as prescribed to prevent hypokalemia. Consuming a potassium rich diet may not be sufficient or safe to correct the potassium imbalance caused by Lasix, especially in clients with kidney impairment or other medications that affect the potassium level.

Choice C reason: Assess the client’s respiratory rate and oxygen saturation is the most appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix can help reduce the fluid overload and congestion in the lungs, which can cause shortness of breath, difficulty breathing, fatigue, and low oxygen levels in clients with heart failure. The nurse should assess the client’s respiratory rate and oxygen saturation to evaluate the severity of the pulmonary edema and the effectiveness of the Lasix therapy. The nurse should also monitor the client’s vital signs, fluid intake and output, and weight to ensure adequate fluid balance and hemodynamic stability.

Choice D reason: Instruct the client to increase fluid intake to prevent dehydration is not an appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix can cause dehydration, which can lead to symptoms such as thirst, dry mouth, dark urine, and fatigue. However, increasing fluid intake to prevent dehydration can worsen the fluid overload and congestion in the lungs, which can cause shortness of breath, difficulty breathing, fatigue, and low oxygen levels in clients with heart failure. The nurse should advise the client to drink enough fluids to maintain hydration, but not to exceed the prescribed fluid restriction, which is usually around 1.52 liters per day. The nurse should also educate the client about the signs and symptoms of dehydration and fluid overload, and when to seek medical attention.

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Correct Answer is ["B","C"]

Explanation

Choice A reason: This is incorrect. Polydipsia is excessive thirst, which is a symptom of hyperglycemia (high blood sugar), not hypoglycemia (low blood sugar). People with hyperglycemia lose fluid through frequent urination and become dehydrated, which makes them thirsty.

Choice B reason: This is correct. Shaking is a common sign of hypoglycemia. It occurs because the body releases adrenaline and other hormones to raise blood sugar levels. Adrenaline causes the muscles to tremble or shake.

Choice C reason: This is correct. Confusion is another common sign of hypoglycemia. It occurs because the brain does not get enough glucose, which is its main source of energy. Low blood sugar can impair cognitive functions, such as memory, attention, and judgment.

Choice D reason: This is incorrect. Tachycardia is a rapid heart rate, which can be a symptom of both hypoglycemia and hyperglycemia. However, it is not a specific or reliable indicator of low blood sugar, as it can also be caused by other factors, such as stress, anxiety, caffeine, or medication.

Choice E reason: This is incorrect. Polyuria is excessive urination, which is another symptom of hyperglycemia, not hypoglycemia. People with hyperglycemia have high levels of glucose in their blood, which draws water from the cells and increases urine output.

A. “This medication should be taken after eating to reduce nausea.” B. “This medication should not be taken with starfruit.” C. “This medication may make me tired and confused.” D. “This medication may cause rebound nausea.”

Correct Answer is C

Explanation

Choice A reason: “This medication should be taken after eating to reduce nausea.” is not a correct statement that demonstrates understanding about ondansetron. Ondansetron is a medication that prevents nausea and vomiting by blocking the action of serotonin, a chemical that stimulates the vomiting center in the brain. Ondansetron can be taken with or without food, and it does not affect the digestion or absorption of food. Ondansetron is usually taken before the start of chemotherapy, radiation, or surgery, which are the common causes of nausea and vomiting.

Choice B reason: “This medication should not be taken with starfruit.” is not a correct statement that demonstrates understanding about ondansetron. Ondansetron is a medication that prevents nausea and vomiting by blocking the action of serotonin, a chemical that stimulates the vomiting center in the brain. Ondansetron does not interact with starfruit, which is a tropical fruit that contains substances that can inhibit the enzyme CYP3A4, which is involved in the metabolism of many drugs. Ondansetron is mainly metabolized by another enzyme, CYP1A2, and it has a low potential for drug interactions¹.

Choice C reason: “This medication may make me tired and confused.” is a correct statement that demonstrates understanding about ondansetron. Ondansetron is a medication that prevents nausea and vomiting by blocking the action of serotonin, a chemical that stimulates the vomiting center in the brain. Ondansetron can also cross the blood brain barrier and affect other serotonin receptors in the brain, which are involved in regulating mood, cognition, and sleep. Ondansetron can cause side effects such as fatigue, drowsiness, headache, and confusion, which can impair the mental alertness and performance of the client. The client should be advised to avoid driving, operating machinery, or doing other tasks that require attention after taking ondansetron.

Choice D reason: “This medication may cause rebound nausea.” is not a correct statement that demonstrates understanding about ondansetron. Ondansetron is a medication that prevents nausea and vomiting by blocking the action of serotonin, a chemical that stimulates the vomiting center in the brain. Ondansetron does not cause rebound nausea, which is a condition of nausea that occurs after the discontinuation of a medication that suppresses nausea. Ondansetron is not a medication that suppresses nausea, but rather prevents it by blocking the stimulation of the vomiting center. Ondansetron does not cause dependence or withdrawal symptoms, and it can be stopped without causing rebound nausea.

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Which of the following interventions is most appropriate for a nurse to perform prior to administering Lasix to a client with heart failure?

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

The client prescribed ondansetron (Zofran) for persistent nausea and vomiting demonstrates understanding about his medication when he states:

Correct Answer is C

Explanation

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