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 C
Explanation
Choice A rationale:
Rifampin does not typically cause insomnia.
Choice B rationale:
Rifampin can cause a red or orange discoloration of body fluids, including urine, not blue or green.
Choice C rationale:
It is recommended to take rifampin on an empty stomach, either 1 hour before or 2 hours after a meal.
Choice D rationale:
Unusual hair growth is not a known side effect of rifampin.
Correct Answer is D
Explanation
Choice A rationale:
Spreading the ointment in a 10 cm² (4 in) area is not the recommended method for nitroglycerin ointment application. The ointment should be applied over a 6x inch area in a thin, uniform layer.
Choice B rationale:
Massaging the ointment into the skin is not advised. The ointment should be applied in a thin layer and left to absorb into the skin.
Choice C rationale:
Applying the ointment in a thick layer is not recommended. A thin, uniform layer is sufficient for therapeutic effect.
Choice D rationale:
Covering the administration area with plastic wrap is the correct action. This helps to keep the ointment in place and enhances absorption.
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