A 70-year-old male receiving high-dose IV furosemide for heart failure complains of ringing in his ears and dizziness. His current labs show normal potassium and sodium levels. What is the nurse's most appropriate intervention?
Increase the infusion rate and check the patient's sodium levels again in 2 hours
Administer potassium supplements and continue the infusion
Reassure the patient that the symptoms are temporary and continue monitoring
Stop the furosemide infusion and notify the provider
The Correct Answer is D
A. Increasing the infusion rate may exacerbate the patient's symptoms and does not address the potential toxicity from the furosemide.
B. Normal potassium levels indicate that potassium supplementation is unnecessary and does not address the dizziness and ringing in the ears, which could suggest ototoxicity from furosemide.
C. While reassurance can help, the patient's symptoms indicate a potential adverse reaction to the medication that should not be ignored.
D. Stopping the furosemide infusion and notifying the provider is the most appropriate action due to the risk of ototoxicity and the need for further evaluation of the patient's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fluid overload is not an allergic reaction but rather a complication of transfusion related to the volume of fluid administered, thus diphenhydramine would not be appropriate.
B. Urticaria, or hives, is a common mild allergic reaction that can occur during blood transfusions. Administering diphenhydramine can help prevent or treat this response.
C. Hemolysis is a serious reaction involving the destruction of red blood cells, often due to blood type incompatibility; it is not alleviated by antihistamines.
D. Fever can occur during transfusions but is typically due to non-specific immune reactions and does not respond to diphenhydramine.
Correct Answer is B
Explanation
A. Blood pressure does not increase during anaphylaxis; instead, it typically decreases due to vasodilation and fluid leakage.
B. During anaphylaxis, blood vessels become more permeable, leading to the release of fluids into the tissues, which causes swelling and contributes to hypotension.
C. Blood vessels do not constrict during anaphylaxis; rather, they dilate as a part of the allergic response, resulting in decreased blood pressure.
D. While there is an immune response during anaphylaxis, white blood cells are not destroyed; rather, they are activated to respond to the allergen, leading to inflammation and other systemic effects.
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