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 C
Explanation
A. Varicella-zoster requires airborne and contact precautions due to the highly contagious nature of chickenpox (varicella) and shingles (zoster).
B. Vancomycin-resistant enterococcus (VRE) typically requires contact precautions to prevent transmission.
C. Pertussis is spread via respiratory droplets, so droplet precautions are necessary to prevent transmission.
D. Rotavirus is transmitted via the fecal-oral route and typically requires contact precautions.
Correct Answer is B
Explanation
A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.
B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.
C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.
D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.
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