A nurse is collecting data from a client who has heart failure and is taking furosemide.

Which of the following findings should indicate to the nurse that the medication is eﬀective?

Decreased hemoglobin level

Increased urinary output

Decreased BUN level

Increased weight of 0.91 kg (2 lb)

Answer and Explanation

The Correct Answer is B

b. Increased urinary output.

Furosemide is a diuretic medication that helps remove excess ﬂuid from the body by increasing urine production and output. In a client with heart failure, one of the indicators that the medication is eﬀective is an increase in urinary output. This can help reduce ﬂuid buildup in the body, which can improve symptoms of heart failure.

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Correct Answer is C

Explanation

The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.

The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.

The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.

The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.

A. Monitor the client's pulse oximetry. B. Instruct the client to massage the calf gently. C. Maintain the leg in a dependent position while in bed. D. Apply a cold compress to the client's calf.

Correct Answer is A

Explanation

Pain in the calf can be a potential symptom of deep vein thrombosis (DVT), which is a serious complication after surgery. Monitoring the client's pulse oximetry can help assess for signs of decreased oxygenation, which may indicate a possible clot or compromised circulation. A decrease in oxygen saturation can be an early indicator of a potential DVT-related complication, such as a pulmonary embolism. Monitoring the pulse oximetry can provide valuable information for timely intervention and management.

Instructing the client to massage the calf gently is not advisable without further assessment and evaluation. Massaging the calf can potentially dislodge a clot if one is present, leading to further complications. It is important to rule out DVT through appropriate diagnostic measures before providing specific instructions for calf massage.

Maintaining the leg in a dependent position while in bed can potentially worsen the symptoms and increase the risk of venous stasis. Elevating the affected leg, rather than maintaining it in a dependent position, can help improve venous return and reduce pain or swelling.

Applying a cold compress to the client's calf is not recommended without further assessment. Heat or cold therapy should be applied based on the underlying cause of the pain. In the case of potential DVT, applying a cold compress can increase vasoconstriction and potentially worsen the condition. It is essential to investigate the cause of the pain first and consult with the healthcare provider before initiating any specific therapies or interventions.

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A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is eﬀective?

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A nurse is collecting data from a client who has heart failure and is taking furosemide.

Which of the following findings should indicate to the nurse that the medication is eﬀective?