A client who is taking furosemide reports experiencing leg cramps, a cough, feeling tired, and palpitations. Which action should the nurse take first?
Apply warm compresses to legs.
Monitor intake and output.
Raise the head of the bed.
Place on cardiac monitoring.
The Correct Answer is D
A. Apply warm compresses to legs:
While leg cramps can be uncomfortable, addressing them with warm compresses does not address the potential underlying issues related to the client's symptoms, especially considering the possibility of more severe conditions.
B. Monitor intake and output:
Monitoring intake and output is important in managing fluid balance, especially with diuretics like furosemide. However, this action does not directly address the immediate concerns raised by symptoms like palpitations and a cough.
C. Raise the head of the bed:
Raising the head of the bed can be helpful if the client is experiencing shortness of breath or orthopnea. However, it does not address the need to evaluate cardiac function, which is crucial given the presence of palpitations and other symptoms.
D. Place on cardiac monitoring:
The client's symptoms—palpitations, cough, fatigue—could indicate significant electrolyte imbalances or cardiac issues, which are common with furosemide use. Cardiac monitoring is the most appropriate initial action to quickly identify and address any cardiac complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. High density lipoprotein (HDL):
HDL levels are important for cardiovascular health as higher levels are associated with a lower risk of coronary artery disease. However, atorvastatin primarily targets LDL levels. While increasing HDL is beneficial, it is not the primary measure of atorvastatin's effectiveness.
B. Low density lipoprotein (LDL):
Atorvastatin is a statin medication used to lower LDL cholesterol levels, which is a major risk factor for coronary artery disease. A decrease in LDL levels indicates that the medication is having its desired effect, reducing the risk of cardiovascular events.
C. Creatine phosphokinase (CK):
CK levels are monitored to assess muscle damage or side effects related to statin use, such as rhabdomyolysis. While important for safety monitoring, changes in CK levels do not directly reflect the effectiveness of atorvastatin in managing cholesterol levels.
D. Prothrombin time (PT):
PT is used to evaluate blood clotting ability and is not directly related to the effectiveness of atorvastatin. It is more relevant for monitoring anticoagulant therapy rather than statin therapy for cholesterol management.
Correct Answer is C
Explanation
A. Do not take the medication more than once every 8 hours:
Diphenhydramine is typically dosed every 4 to 6 hours, not just once every 8 hours. However, this instruction is less critical compared to addressing the safety concerns related to drowsiness.
B. Take the medication with food to prevent gastric upset:
Diphenhydramine is generally not known to cause significant gastric upset, so this instruction is less critical. The primary concern with diphenhydramine is its sedative effects rather than gastrointestinal issues.
C. Avoid driving, since this medication causes drowsiness:
Diphenhydramine is known to cause significant drowsiness and sedation. Advising the client to avoid driving is crucial to prevent accidents and ensure their safety, making this the most important instruction.
D. Use sugarless candy or gum to help prevent a dry mouth:
While diphenhydramine can cause dry mouth, using sugarless candy or gum is a helpful but secondary instruction. The primary concern with diphenhydramine is its sedative effect, which affects the client's ability to drive safely.
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