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 C
Explanation
A. Notifying the facility operator is important, but it is not the immediate priority when there is a fire endangering the client's safety.
B. While closing fire doors can help contain the fire, it is not the priority action after ensuring the client's immediate safety.
C. Turning off oxygen sources is crucial because oxygen can fuel the fire and cause it to spread rapidly. This action helps prevent the fire from worsening.
D. Putting out the fire with the appropriate extinguisher is important, but it comes after ensuring the fire's fuel source is cut off to prevent further escalation of the fire.
Correct Answer is A
Explanation
A. Providing a flexible activity schedule allows the client to engage in activities that match their energy level and interests, promoting a sense of control and reducing agitation during acute
mania.
B. High-calorie nutritional supplements are not typically indicated solely based on the diagnosis of acute mania. Nutritional needs should be assessed, but providing high-calorie supplements
may not address the underlying issues associated with mania.
C. Allowing the client to eat meals alone in her room may not be safe or therapeutic during acute mania, as supervision during meals can ensure adequate nutrition and prevent potential harm or
inappropriate behaviors.
D. While promoting independence is important, allowing the client to choose her clothes independently may not be appropriate during acute mania, as it could result in wearing
inappropriate attire or exacerbate impulsivity.
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