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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Peak level is the correct term to describe the highest concentration of a drug in the blood after it is administered. Peak level is also known as peak plasma concentration or Cmax, and it reflects the rate and extent of drug absorption. Peak level is influenced by factors such as the route of administration, the dose, the formulation, and the bioavailability of the drug. Peak level is important to monitor for drugs that have a narrow therapeutic range, meaning that there is a small difference between the effective and toxic doses. The nurse should measure the peak level at the appropriate time after the drug administration, and adjust the dose or the frequency as needed to achieve the desired therapeutic effect and avoid adverse effects .
Choice B reason: Halflife is not the correct term to describe the highest concentration of a drug in the blood after it is administered. Halflife is the time it takes for the concentration of a drug in the blood to decrease by 50%. Halflife reflects the rate of drug elimination, which depends on factors such as the metabolism and excretion of the drug. Halflife is important to determine the dosing interval and the time to reach steady state. The nurse should consider the halflife of the drug when prescribing or administering the drug, and avoid drug accumulation or subtherapeutic levels .
Choice C reason: Trough level is not the correct term to describe the highest concentration of a drug in the blood after it is administered. Trough level is the lowest concentration of a drug in the blood before the next dose is given. Trough level reflects the balance between drug absorption and elimination, and it indicates the minimum effective concentration of the drug. Trough level is important to monitor for drugs that have a narrow therapeutic range, meaning that there is a small difference between the effective and toxic doses. The nurse should measure the trough level just before the next dose of the drug, and adjust the dose or the frequency as needed to achieve the desired therapeutic effect and avoid adverse effects .
Choice D reason: Steady state is not the correct term to describe the highest concentration of a drug in the blood after it is administered. Steady state is the condition when the rate of drug administration is equal to the rate of drug elimination, and the concentration of the drug in the blood remains constant. Steady state is usually reached after four to five halflives of the drug, and it reflects the optimal therapeutic level of the drug. Steady state is important to maintain for drugs that have a long halflife or a narrow therapeutic range, meaning that there is a small difference between the effective and toxic doses. The nurse should ensure that the drug is administered at regular intervals and at the appropriate dose to achieve and maintain steady state.
Correct Answer is C
Explanation
Choice A reason: Limit caffeine intake is not an instruction that the nurse should provide to the client who has asthma and a new prescription for inhaled fluticasone. Fluticasone is a medication that reduces inflammation and swelling in the airways, which can improve breathing and prevent asthma attacks. Fluticasone does not interact with caffeine or affect the heart rate or blood pressure. Caffeine is a stimulant that can cause nervousness, insomnia, or palpitations in some people, but it does not worsen asthma symptoms or interfere with fluticasone therapy. The nurse should advise the client to consume caffeine in moderation and avoid it before bedtime.
Choice B reason: Take the medication with meals is not an instruction that the nurse should provide to the client who has asthma and a new prescription for inhaled fluticasone. Fluticasone is a medication that reduces inflammation and swelling in the airways, which can improve breathing and prevent asthma attacks. Fluticasone is administered by inhalation, not by mouth, and it does not affect the digestion or absorption of food. The nurse should instruct the client to use the inhaler as prescribed, usually twice a day, regardless of the mealtimes.
Choice C reason: Rinse the mouth after administration is an instruction that the nurse should provide to the client who has asthma and a new prescription for inhaled fluticasone. Fluticasone is a medication that reduces inflammation and swelling in the airways, which can improve breathing and prevent asthma attacks. Fluticasone is a corticosteroid, which can cause side effects such as oral thrush, hoarseness, or sore throat if it remains in the mouth after inhalation. The nurse should instruct the client to rinse the mouth with water and spit it out after each dose of fluticasone to prevent these side effects. The nurse should also teach the client how to use the inhaler properly and check the inhaler technique regularly.
Choice D reason: Check the pulse after medication administration is not an instruction that the nurse should provide to the client who has asthma and a new prescription for inhaled fluticasone. Fluticasone is a medication that reduces inflammation and swelling in the airways, which can improve breathing and prevent asthma attacks. Fluticasone does not affect the heart rate or blood pressure, and it is not a rescue medication that should be used for acute asthma symptoms. The nurse should monitor the respiratory rate and the oxygen saturation of the client after administering fluticasone and advise the client to use a short acting bronchodilator, such as albuterol, for quick relief of wheezing or shortness of breath.
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