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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A urine output of 600 mL in 8 hours is within the normal range. The average urine output for adults is about 1 to 2 liters per day.
Choice B rationale:
Clonidine is an antihypertensive medication. If the client’s blood pressure is already low (88/50 mm Hg), administering clonidine could further lower the blood pressure and cause hypotension.
Choice C rationale:
A heart rate of 110/min is slightly high, but it’s not a direct indication to withhold clonidine. Clonidine can actually help lower an elevated heart rate by reducing the levels of certain chemicals in your blood.
Choice D rationale:
A blood glucose level of 70 mg/dL is at the lower end of the normal range (70-100 mg/dL) However, clonidine does not directly affect blood glucose levels, so this would not be a reason to withhold the medication.
Correct Answer is B
Explanation
Choice A rationale:
While it’s important for the client to maintain a balanced diet, consuming a lot of protein with each meal does not specifically benefit a person taking levodopa/carbidopa for Parkinson’s disease.
Choice B rationale:
Levodopa/carbidopa can cause side effects such as uncontrolled muscle movements in the face, arms, legs, or trunk. Therefore, monitoring for an increase in unusual movements is a sign of understanding the potential side effects of the medication.
Choice C rationale:
Levodopa/carbidopa helps manage the symptoms of Parkinson’s disease but does not prevent the disease from progressing.
Choice D rationale:
While levodopa/carbidopa can help reduce symptoms such as stiffness and tremors, it does not typically result in a rapid improvement in condition.
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