A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

A Administer albuterol via nebulizer.

Listen to the lungs fields.

Measure urine output.

Review serum potassium.

Answer and Explanation

The Correct Answer is B

A. Administering albuterol may help if the shortness of breath is due to bronchospasm, but the priority in heart failure is to assess fluid status and respiratory function.
B. Listening to lung fields is crucial to assess for signs of pulmonary edema, which is a common complication in heart failure. This assessment helps determine the effectiveness of the furosemide and whether further intervention is needed.
C. Measuring urine output is important but secondary to assessing respiratory status.
D. Reviewing serum potassium is important but not as urgent as assessing the client's respiratory status.

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Correct Answer is C

Explanation

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.
B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.
C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.
D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

A. Intranasal edema and swelling of turbinates. B. Purulent secretions from eyes and nares. C. Snoring and bilateral, pale gray nodules. D. Eye tearing and thick yellow nasal drainage.

Correct Answer is A

Explanation

A. Allergic rhinitis is characterized by intranasal edema and swelling of the turbinates due to inflammation caused by allergens. This is a common physical finding in clients with allergic rhinitis.
B. Purulent secretions typically indicate an infection rather than an allergic condition.
C. Bilateral, pale gray nodules might suggest nasal polyps, which are associated with chronic sinusitis rather than acute allergic rhinitis.
D. Eye tearing is common in allergic rhinitis, but thick yellow nasal drainage suggests an infection rather than an allergic reaction.

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A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?