A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?

“I’m urinating in larger amounts.”

“I have to sleep sitting up.”

“I suck on hard candy for my dry mouth.”

“I’ve lost 3 pounds in the last week.”

Answer and Explanation

The Correct Answer is B

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

Blood pressure: less than 140/90 mmHg
Heart rate: 60 to 100 beats per minute
Respiratory rate: 12 to 20 breaths per minute
Oxygen saturation: greater than 95%
Weight: stable or decreasing within 2 to 4 pounds per week

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Correct Answer is C

Explanation

This is a manifestation of a fat embolism, which is a condition where particles of fat get into the bloodstream and block blood flow. A fat embolism can occur after trauma or surgery to the legs, when fat from the bone marrow escapes into the bloodstream.

Choice A is wrong because a report of pain as 6 on a scale of 0 to 10 is not specific to a fat embolism.

Pain is a common symptom of many conditions and injuries.

Choice B is wrong because pulses 2+ distal to the client’s fracture are normal and indicate adequate blood flow to the extremity.

Choice D is wrong because bruising around the fracture site is an expected finding after a compound fracture and does not indicate a fat embolism.

Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg and for heart rate are 60 to 100 beats per minute.

Petechiae are small red or purple spots on the skin caused by bleeding under the skin.

They can range in size from pinpoint to several millimeters. Fat embolism syndrome (FES) is a serious complication of a fat embolism that affects the lungs, skin or brain and can be fatal. FES usually occurs 12 to 72 hours after trauma.

A. Begin an amnioinfusion for the client. B. Prepare the client for a cesarean birth. C. Administer ampicillin IV to the client. D. Initiate an oxytocin infusion for the client.

Correct Answer is B

Explanation

Prepare the client for a cesarean birth.

This is because the client has herpes simplex virus with active lesions, which can be transmitted to the newborn during vaginal delivery and cause serious complications such as neonatal herpes infection. A cesarean birth can prevent this transmission and protect the newborn’s health.

Choice A is wrong because an amnioinfusion is a procedure that involves infusing fluid into the amniotic cavity to increase the volume of amniotic fluid and reduce cord compression.

It is not indicated for a client with herpes simplex virus with active lesions.

Choice C is wrong because ampicillin is an antibiotic that is used to treat bacterial infections, not viral infections such as herpes simplex virus.

Ampicillin will not prevent the transmission of herpes simplex virus to the newborn.

Choice D is wrong because oxytocin is a hormone that stimulates uterine contractions and can be used to augment or induce labor.

It is not indicated for a client with herpes simplex virus with active lesions, as it can increase the risk of transmission to the newborn by prolonging the exposure to infected genital secretions.

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A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following statements by the client indicates a need for the nurse to intervene?

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A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?