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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Dissolving the medication in 30 mL of water is the correct action. This ensures that the medication is in a suitable form for administration via an NG tube and helps prevent the tube from becoming blocked.
Choice B rationale:
Maintaining the client in the supine position during medication administration is not recommended. This position increases the risk of aspiration. Instead, the client should be in an upright position during medication administration and for at least 30 minutes afterward.
Choice C rationale:
Adding the medication to the enteral feeding formula is not recommended. This can alter the effectiveness of the medication and can also clog the feeding tube.
Choice D rationale:
Flushing the tube with 5 mL of water after administering the medication is not enough. The tube should be flushed with at least 15-30 mL of water before and after medication administration to ensure that the entire dose has been administered and to prevent clogging of the tube.
Correct Answer is B
Explanation
Choice A rationale:
Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used for pain relief after surgery. However, it’s not typically administered every 3 hours. Overuse can lead to serious side effects.
Choice B rationale:
If the client’s pain level remains high after receiving ketorolac, administering an opioid medication like oxycodone may be appropriate.
Choice C rationale:
While acetaminophen can be used for pain relief, rectal administration is not typically the first choice for postoperative pain management.
Choice D rationale:
It’s inappropriate to label a patient as exhibiting drug-seeking behaviors simply because their reported pain level remains high after medication. Pain is subjective and should be addressed appropriately.
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