A nurse is caring for a client in a clinic.

For each body system below, click to specify the adverse effect that the nurse should include in the teaching. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.

Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	_____
Cardiovascular	_____
Genitourinary	_____
Gastrointestinal	_____

A. "Eat foods that are high in sodium.": Clients taking furosemide should limit sodium intake because high sodium can cause fluid retention, which worsens heart failure. Encouraging high-sodium foods would counteract the effects of the diuretic.

B. "Taking furosemide can cause your potassium levels to be high.": Furosemide is a loop diuretic that increases potassium excretion, which can lead to hypokalemia, not hyperkalemia. Clients need to monitor for low potassium symptoms and may require potassium supplementation.

C. "Taking furosemide can cause you to be overhydrated.": Furosemide promotes fluid loss through diuresis, so overhydration is unlikely; instead, clients are at risk for dehydration and electrolyte imbalances if fluid loss is excessive.

D. "Rise slowly when getting out of bed.": Furosemide can cause orthostatic hypotension due to rapid fluid loss. Advising the client to rise slowly helps prevent dizziness or falls, making this an important safety teaching point.

A. State Nurse Practice Act: The State Nurse Practice Act defines the legal scope of practice for nurses within that state, including permissible tasks, delegation guidelines, and licensure requirements. Consulting it ensures that the nurse acts within legal and professional boundaries.

B. Verbal direction from the nurse manager: While guidance from a manager can clarify expectations, it does not supersede legal regulations or define the nurse’s authorized scope of practice. Following only verbal instructions without legal backing may place the nurse at risk of practicing outside their scope.

C. Institutional policies and procedures: Policies provide guidance on how tasks should be performed safely within a facility, but they do not define the nurse’s legal scope of practice. These should be used in conjunction with state regulations, not as the primary authority.

D. Written prescription from the provider: A provider’s order indicates what care is needed for the client but does not grant a nurse legal authority to perform tasks outside their scope of practice. The nurse must ensure the action is permitted under state law before implementation.