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
None
None
The Correct Answer is A
A. Decreased reflexes can indicate electrolyte imbalance, particularly hypokalemia, which is a common adverse effect of loop diuretics. Low potassium levels can affect neuromuscular function and should be reported and addressed promptly.
B. A weight gain of 1.4 kg (3 lb) suggests fluid retention and worsening heart failure, not an adverse effect of the diuretic. Loop diuretics are expected to promote weight loss through fluid removal.
C. Increased urinary output is an expected therapeutic effect of a loop diuretic and indicates the medication is working as intended.
D. Jugular vein distention reflects fluid volume overload associated with heart failure rather than an adverse medication effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A: A heart rate greater than 60/min indicates that the transcutaneous pacing is effectively maintaining a heart rate within a normal range, which is crucial for adequate cardiac output and systemic perfusion.
- B: While 2+ pedal pulses indicate good peripheral perfusion, they do not directly reflect the effectiveness of transcutaneous pacing in treating complete heart block.
- C: Pacer spikes should appear before the QRS complex to show that the pacing stimulus is being delivered appropriately. Spikes after the QRS complex suggest that the pacing is not capturing the heart effectively.
- D: Distended jugular veins would be more indicative of heart failure or fluid overload and do not directly relate to the effectiveness of pacing therapy.
Correct Answer is C
Explanation
A. Rupturing the amniotic sac in the case of complete placenta previa can lead to significant bleeding and is contraindicated.
B. Pain medication may be administered if needed, but the priority is to address the placenta previa and potential complications.
C. Complete placenta previa at 36 weeks gestation with contractions and bleeding is a clear
indication for an emergency cesarean section to prevent maternal hemorrhage and fetal distress.
D. Performing a vaginal exam can increase the risk of bleeding and should be avoided in cases of placenta previa.
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