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 (3 lb)
Increased urinary output
Jugular vein distention
The Correct Answer is A
Rationale for A: Decreased reflexes can indicate hypokalemia, an adverse effect of loop diuretics. Loop diuretics increase the excretion of potassium, which can lead to low potassium levels, manifesting as muscle weakness and diminished reflexes.
Rationale for B: Weight gain, especially in the context of heart failure, suggests fluid retention rather than an adverse effect of a loop diuretic, which is expected to reduce fluid retention by promoting diuresis.
Rationale for C: Increased urinary output is an expected effect of loop diuretics, as they are used to remove excess fluid. This would not be considered an adverse effect unless it leads to dehydration or electrolyte imbalances.
Rationale for D: Jugular vein distention indicates fluid overload, which would suggest that the diuretic is not effective or that the heart failure is worsening. It is not a direct adverse effect of the medication itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. A BMI of 20 falls within the healthy weight range for adults.
B. Malnutrition is characterized by a BMI below the healthy weight range and is typically associated with BMI values less than 18.5.
C. Overweight is characterized by a BMI between 25 and 29.9.
D. Obesity is characterized by a BMI of 30 or higher.
Correct Answer is B
Explanation
A. The wall suction setting does not directly indicate the functioning of the NG tube.
B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting
that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.
C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.
D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.
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