A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?
Decreased reflexes
Weight gain of 1.4 kg (3b)
Increased urinary output
Jugular vein distention
The Correct Answer is A
A. Decreased reflexes: Loop diuretics can cause electrolyte imbalances, particularly hypokalemia and hypomagnesemia. Hypokalemia can lead to neuromuscular changes, including decreased reflexes, muscle weakness, and potentially life-threatening cardiac arrhythmias. This is an adverse effect that requires prompt assessment and intervention.
B. Weight gain of 1.4 kg (3 lb): Weight gain in heart failure may indicate fluid retention, but a loop diuretic typically promotes diuresis. A small weight gain of 1.4 kg is not immediately indicative of an adverse effect from the medication itself and may reflect other factors, such as fluid shifts or diet.
C. Increased urinary output: Increased urinary output is the intended therapeutic effect of loop diuretics. It indicates that the medication is working to reduce fluid overload rather than an adverse effect.
D. Jugular vein distention: Jugular vein distention is a sign of fluid overload in heart failure. While it may indicate insufficient therapeutic response, it is not a direct adverse effect of the loop diuretic. Monitoring and adjusting therapy may be necessary, but it is not a medication-related complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Rationale for correct choices
• Shortness of breath: The client’s dyspnea indicates impaired oxygenation and potential progression of pneumonia or respiratory compromise. Rapid recognition is essential to prevent hypoxemia or respiratory failure. Persistent shortness of breath warrants immediate interventions such as supplemental oxygen, monitoring, and notifying the provider.
• Productive cough with yellow sputum: The sputum color and productivity suggest a bacterial respiratory infection, which is confirmed by the chest x-ray result (pneumonia) and elevated WBC count. This requires immediate treatment with antibiotics.
• Diminished lung sounds with crackles: Diminished breath sounds and crackles suggest alveolar consolidation or fluid accumulation in the lungs, consistent with pneumonia. These findings indicate impaired gas exchange and increased work of breathing. Prompt assessment ensures early intervention and prevents deterioration.
• Pleuritic chest pain rated 6/10: Moderate chest pain on inspiration can indicate inflammation of the pleura secondary to pneumonia or early complications such as empyema. Pain may limit deep breathing and coughing, increasing the risk of atelectasis and further respiratory compromise. Follow-up ensures pain management and effective pulmonary hygiene.
Rationale for Incorrect Findings
• Nausea without vomiting: While the client reports nausea, it is mild and not associated with dehydration or electrolyte disturbances at this time. It should be monitored but does not require immediate intervention.
• Able to move all extremities and oriented: Neurological status is intact, which is reassuring. No deficits are noted, and immediate follow-up is not required.
• Skin is moist, pedal pulses +2: Perfusion appears adequate. Vital signs and circulation findings do not indicate acute compromise needing urgent intervention.
• Bowel sounds normoactive, last bowel movement this morning, no difficulty urinating: Gastrointestinal and urinary functions are stable. These findings do not require immediate follow-up.
Correct Answer is D
Explanation
A. Plan the incorporation of new behaviors into daily life: This is part of the working phase of the therapeutic relationship, where interventions are implemented and the client practices new behaviors. It is not the focus of the orientation phase.
B. Promote the client's dependence on the caregiver: The goal of therapeutic relationships is to foster autonomy, trust, and self-efficacy, not dependence. Encouraging dependence can hinder the client’s progress and is not appropriate at any phase.
C. Solve problems using a model applicable to the client's perspective: Problem-solving occurs primarily during the working phase, once trust is established and goals are clear. It is not the main objective during the orientation phase.
D. Mutually decide on the goals for the client's treatment: The orientation phase focuses on building trust, establishing rapport, and collaboratively identifying goals for treatment. Engaging the client in goal setting ensures clarity, promotes cooperation, and sets the foundation for a therapeutic relationship.
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