A client hospitalized for heart failure exacerbation has been receiving 40 mg furosemide IV twice daily. What statement by the client would alert the nurse to a possible toxic effect of this medication?
This IV site seems irritated. It's red and painful.
I feel like I've done nothing but urinate since I've been here.
Everything has started sounding muffled, I'm having difficulty hearing.
My stomach is distended, and I haven't had a bowel movement in 3 days.
The Correct Answer is C
Choice A reason: This statement is false. The nurse would not be alerted to a possible toxic effect of furosemide by this statement, as this statement indicates a local reaction to the IV site, not a systemic effect of the medication. Furosemide is a diuretic that increases the urine output and reduces the fluid volume in the body. It does not cause irritation, redness, or pain at the IV site. However, the nurse should still inspect the IV site and change it if needed.
Choice B reason: This statement is false. The nurse would not be alerted to a possible toxic effect of furosemide by this statement, as this statement indicates an expected effect of the medication, not a toxic effect. Furosemide is a diuretic that increases the urine output and reduces the fluid volume in the body. It is used to treat heart failure, which is a condition where the heart cannot pump enough blood to meet the body's needs. This causes fluid to accumulate in the lungs, the legs, or the abdomen. By increasing the urine output, furosemide helps to remove the excess fluid and relieve the symptoms of heart failure.
Choice C reason: This statement is true. The nurse would be alerted to a possible toxic effect of furosemide by this statement, as this statement indicates a sign of ototoxicity, which is a damage to the inner ear caused by the medication. Furosemide is a diuretic that increases the urine output and reduces the fluid volume in the body. However, it can also affect the electrolyte balance and the blood flow in the inner ear, which can impair the hearing and cause tinnitus, vertigo, or deafness. Ototoxicity is a serious and sometimes irreversible complication of furosemide therapy. The nurse should stop the medication and notify the prescriber immediately.
Choice D reason: This statement is false. The nurse would not be alerted to a possible toxic effect of furosemide by this statement, as this statement indicates a sign of constipation, which is a common and mild side effect of the medication. Furosemide is a diuretic that increases the urine output and reduces the fluid volume in the body. However, it can also cause dehydration and electrolyte imbalance, which can affect the bowel movements and cause constipation. Constipation is not a life-threatening condition, but it can cause discomfort and complications if not treated. The nurse should advise the client to drink plenty of fluids, eat high-fiber foods, and use laxatives or stool softeners as needed.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is false. If the client develops facial swelling, which is a sign of angioedema, she should stop taking the medication and seek emergency care. Reducing the dose will not prevent a life-threatening reaction.
Choice B reason: This statement is true. Captopril is an angiotensin-converting enzyme (ACE) inhibitor, which can cause fetal harm or death if taken during pregnancy. The client should use effective contraception and inform the provider if she plans to conceive or suspects pregnancy.
Choice C reason: This statement is false. Captopril can be taken with or without food, but it should not be taken with milk or dairy products, as they can reduce its absorption and effectiveness.
Choice D reason: This statement is false. Captopril may cause a dry cough, hypotension, hyperkalemia, or renal impairment, but it is unlikely to cause anaphylaxis. An epi pen is not indicated for this medication.
Correct Answer is B
Explanation
Choice A reason: This statement is false. The nurse should not delay the administration of digoxin based on the heart rate alone, unless it is below 60 beats per minute. The nurse should also consider the serum potassium level, which is low in this case and increases the risk of digoxin toxicity.
Choice B reason: This statement is true. The nurse should hold the digoxin and call the MD, as the client has a low potassium level, which can potentiate the effects of digoxin and cause arrhythmias, nausea, vomiting, or visual disturbances. The MD may order a serum digoxin level, potassium supplementation, or a dose adjustment.
Choice C reason: This statement is false. The nurse does not need to call the prescriber and ask for a chest x-ray, as this is not relevant to the digoxin order. A chest x-ray may be indicated to assess the severity of heart failure, but it does not affect the decision to administer digoxin.
Choice D reason: This statement is false. The nurse should not give the digoxin as ordered, as the client has a low potassium level, which can increase the risk of digoxin toxicity. The nurse should hold the digoxin and call the MD for further instructions..
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