A nurse is administering furosemide IV bolus to a client who has fluid volume excess.

The nurse should recognize which of the following findings as an indication that the medication has been effective?

Weight loss.

Decreased inflammation.

Increased blood pressure.

Decreased pain.

Answer and Explanation

The Correct Answer is A

The correct answer is A.

Weight loss.

Furosemide is a loop diuretic that is used to treat fluid volume excess by increasing the excretion of water and electrolytes through the kidneys. Weight loss is an indication that the medication has been effective in reducing the excess fluid in the body.

Choice B is wrong because decreased inflammation is not a direct effect of furosemide.

Inflammation is a response to tissue injury or infection, and furosemide does not have any anti-inflammatory properties.

Choice C is wrong because increased blood pressure is not an indication of furosemide effectiveness.

Furosemide lowers blood pressure by reducing the preload and afterload on the heart.

Increased blood pressure may indicate that the dose of furosemide is insufficient or that there are other factors contributing to hypertension.

Choice D is wrong because decreased pain is not an expected outcome of furosemide therapy.

Furosemide does not have any analgesic effects, and pain may be caused by various conditions that are not related to fluid volume excess.

Normal ranges for weight, blood pressure and pain vary depending on the individual patient’s baseline and goals.

However, some general guidelines are:

Weight: A weight loss of 0.5 to 1 kg per day is considered safe and effective for patients with fluid volume excess.
Blood pressure: The target blood pressure for most patients with heart failure is less than 130/80 mmHg.
Pain: The pain level should be assessed using a valid and reliable scale, such as the numeric rating scale or the visual analogue scale, and treated according to the patient’s preference and tolerance.

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Correct Answer is D

Explanation

Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.

These areas are less affected by melanin, the pigment that gives skin its color.

Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.

Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.

Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.

A. Inserts the catheter without applying suction. B. Waits for 2 min between suctions. C. Applies suction for 15 seconds. D. Encourages the client to cough during suctioning

Correct Answer is B

Explanation

The correct answer is choiceb. Waits for 2 min between suctions.

Choice A rationale:

Inserting the catheter without applying suction is correct. Suction should only be applied while withdrawing the catheter to prevent trauma to the tracheal mucosa.

Choice B rationale:

Waiting for 2 minutes between suctions is too long.The appropriate wait time is generally around 20-30 seconds to 1 minute between suction attempts to prevent hypoxia and allow the patient to recover.

Choice C rationale:

Applying suction for 15 seconds is within the recommended duration.Suctioning should not exceed 15 seconds to avoid causing hypoxia and trauma to the tracheal mucosa.

Choice D rationale:

Encouraging the client to cough during suctioning is appropriate.Coughing helps to mobilize secretions and can make suctioning more effective.

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A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

Nursing Test Bank

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Correct Answer is B

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A nurse is administering furosemide IV bolus to a client who has fluid volume excess.

The nurse should recognize which of the following findings as an indication that the medication has been effective?