A nurse is caring for an older adult client who has heart failure and a prescription for a repeat dose of furosemide 40 mg orally.
Which of the following actions is the nurse's priority?

Remind the client to change positions slowly.

Prepare the client's medication.

Record the client's urinary output.

Review the client's electrolyte levels.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

While reminding the client to change positions slowly is important to prevent orthostatic hypotension, it is not the priority before administering furosemide.

Choice B rationale:

Preparing the client’s medication is an important step, but it should be done after reviewing the client’s electrolyte levels.

Choice C rationale:

Recording the client’s urinary output is important when administering furosemide, a diuretic, but it is not the priority action.

Choice D rationale:

Reviewing the client’s electrolyte levels is crucial before administering furosemide because it can cause electrolyte imbalances, including low potassium levels, which can lead to serious cardiac complications.

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Correct Answer is C

Explanation

Choice A rationale:

Increased temperature is not a direct indication of naloxone’s effectiveness. Naloxone works by reversing the effects of opioids, which do not typically include fever.

Choice B rationale:

While naloxone can cause an abrupt withdrawal in opioid-dependent individuals, leading to symptoms such as hypertension, it does not typically decrease blood pressure in opioid overdose cases.

Choice C rationale:

Naloxone works by reversing the life-threatening depression of the central nervous system and respiratory system caused by an opioid overdose. Therefore, an increased respiratory rate after administration would indicate that the medication is effective.

Choice D rationale:

Naloxone reverses the effects of opioids, including pain relief. Therefore, a report of decreased pain would not indicate that the medication is effective.

A. Check blood pressure with the client standing. B. Administer a 0.9% sodium chloride IV bolus. C. Place the client in a supine position. D. Measure blood pressure with the client sitting.

Correct Answer is C

Explanation

Choice A rationale:

Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.

Choice B rationale:

Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.

Choice C rationale:

Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.

Choice D rationale:

Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.

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A nurse is caring for an older adult client who has heart failure and a prescription for a repeat dose of furosemide 40 mg orally.Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is caring for an older adult client who has heart failure and a prescription for a repeat dose of furosemide 40 mg orally.
Which of the following actions is the nurse's priority?