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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Free Nursing Study Resources

Correct Answer is ["A","C","D","E","F"]

Explanation

The correct answer is: a. Right route, c. Right dose, d. Right person, e. Right documentation, f. Right medication.

Choice A: Right route

The right route ensures that the medication is administered via the correct method, such as oral, intravenous, or intramuscular. This is crucial because different routes can affect the medication’s absorption and effectiveness. Administering medication via the wrong route can lead to ineffective treatment or even harm the patient.

Choice B: Right to refuse

While patients do have the right to refuse medication, this is not one of the five main rights of medication administration. The five main rights focus on the correct administration process to ensure patient safety and effective treatment.

Choice C: Right dose

The right dose ensures that the patient receives the correct amount of medication. Administering too much or too little can lead to adverse effects or ineffective treatment. This right involves verifying the prescribed dose and measuring it accurately.

Choice D: Right person

The right person ensures that the medication is given to the correct patient. This is typically verified using two identifyers, such as the patient’s name and date of birth, to prevent medication errors.

Choice E: Right documentation

The right documentation involves accurately recording the administration of the medication. This includes noting the time, dose, route, and any observations. Proper documentation is essential for maintaining accurate medical records and ensuring continuity of care.

Choice F: Right medication

The right medication ensures that the correct drug is given to the patient. This involves checking the medication label against the doctor’s order to prevent errors. Administering the wrong medication can have serious consequences.

A. Review the patient’s previous blood glucose levels B. No review is necessary before administering insulin C. Review the Regular insulin sliding scale for administration in the patient’s electronic medical record D. Review the patient’s previous insulin administration doses

Correct Answer is C

Explanation

Choice A reason: This is incorrect. Reviewing the patient’s previous blood glucose levels may not be helpful in determining the correct dose of insulin, as the blood glucose level can fluctuate depending on various factors, such as food intake, activity, stress, and illness. The previous blood glucose levels may not reflect the current insulin needs of the patient¹.

Choice B reason: This is incorrect. No review is not an option before administering insulin, as insulin is a highalert medication that can cause serious harm if given incorrectly. The nurse should always check the patient’s blood glucose level, the insulin order, the insulin type, the insulin dose, the insulin expiration date, and the insulin injection site before giving insulin.

Choice C reason: This is correct. Reviewing the Regular insulin sliding scale for administration in the patient’s electronic medical record is the best action to determine the correct dose of insulin. A sliding scale is a chart of insulin dosages based on blood glucose level and mealtime. It is used to adjust the insulin dose according to the patient’s blood glucose level and insulin sensitivity. The nurse should follow the sliding scale protocol and verify the insulin dose with another nurse before administering it.

Choice D reason: This is incorrect. Reviewing the patient’s previous insulin administration doses may not be helpful in determining the correct dose of insulin, as the insulin dose may vary depending on the patient’s blood glucose level and insulin sensitivity. The previous insulin doses may not reflect the current insulin needs of the patient¹.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following are the five main rights of medication administration?(Select all that apply.)

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A: Right route

Choice B: Right to refuse

Choice C: Right dose

Choice D: Right person

Choice E: Right documentation

Choice F: Right medication

The nurse is preparing to administer Regular insulin to a client with a blood glucose of 265. What action should the nurse take to determine the correct dose?

Correct Answer is C

Explanation

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