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 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.

A. Dry mouth. B. Nausea. C. Agitation. D. Dizziness.

Correct Answer is C

Explanation

Choice A rationale:

Dry mouth is a common side effect of diphenhydramine. Diphenhydramine is an antihistamine that is often used to treat allergies, insomnia, and symptoms of the common cold. It works by blocking the effects of histamine, a substance in the body that causes allergy symptoms. One of the effects of histamine is increased salivation, so when diphenhydramine blocks this effect, it can lead to dry mouth.

Choice B rationale:

Nausea is also a common side effect of diphenhydramine. This can occur because diphenhydramine can slow down the emptying of the stomach, leading to feelings of nausea. Additionally, diphenhydramine can affect the vestibular system in the inner ear, which can also lead to feelings of nausea.

Choice C rationale:

Agitation is considered an idiosyncratic reaction to diphenhydramine. An idiosyncratic reaction is an unusual or unexpected reaction to a drug that is not related to the usual pharmacological action of the drug. While diphenhydramine is typically used for its sedative effects, in some cases it can cause paradoxical central nervous system stimulation, leading to agitation.

Choice D rationale:

Dizziness is another common side effect of diphenhydramine. This occurs because diphenhydramine can affect the vestibular system in the inner ear, which plays a key role in maintaining balance. When this system is affected, it can lead to feelings of dizziness.

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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

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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?