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 C
Explanation
A. Avoid taking the medication on an empty stomach:
While it can be helpful to take lithium with food to minimize gastrointestinal upset, it is not the primary instruction for lithium use. The most important aspect of lithium therapy involves fluid balance and monitoring.
B. Keep medication fliers for frequent review and reference:
While reviewing medication information is useful, it is not as critical as maintaining appropriate fluid intake and monitoring for side effects specific to lithium.
C. Maintain a fluid intake of 1500 to 3000 mL per day:
This is crucial because lithium levels can be affected by changes in fluid balance. Inadequate fluid intake can lead to dehydration, which can increase lithium levels and the risk of toxicity. Therefore, maintaining adequate hydration is essential for safe lithium use.
D. Report fluctuations in weight to the healthcare provider:
While fluctuations in weight can be relevant for overall health monitoring, the more immediate concern with lithium therapy is to maintain proper fluid intake and monitor for signs of toxicity or dehydration.
Correct Answer is C
Explanation
A. Digoxin level of 1.1 ng/mL (1.4 nmol/L):
A digoxin level of 1.1 ng/mL is within the therapeutic range (0.8 to 2.0 ng/mL). While it is important to monitor digoxin levels, this value does not indicate an immediate concern.
B. Creatinine level of 0.8 mg/dL (70.72 μmol/L):
A creatinine level of 0.8 mg/dL is within the normal range (0.5 to 1.1 mg/dL) and does not indicate any renal impairment or immediate issue.
C. Potassium level of 3.2 mEq/L (3.2 mmol/L):
A potassium level of 3.2 mEq/L is below the normal range (3.5 to 5.0 mEq/L). Hypokalemia can increase the risk of digoxin toxicity and arrhythmias, making this an urgent issue that should be reported to the healthcare provider immediately.
D. Sodium level of 135 mEq/L (135 mmol/L):
A sodium level of 135 mEq/L is slightly below the normal range (136 to 145 mEq/L), but it is not as critical as a significantly abnormal potassium level in the context of digoxin use. While it should be monitored, it is less urgent compared to the potassium level.
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