A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide.
For which of the following findings should the nurse withhold the medication?

Oxygen saturation of 95%.

Serum sodium level of 140 mEq/L.

Blood pressure of 80/40 mm Hg.

Serum potassium level of 4.8 mEq/L.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

Choice A: Oxygen saturation of 95% The normal oxygen saturation level is between 95% and 100%. An oxygen saturation of 95% is within the normal range, so the nurse would not need to withhold furosemide for this reason.

Choice B: Serum sodium level of 140 mEq/L The normal serum sodium levels range from 135 to 145 mEq/L. A serum sodium level of 140 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.

Choice C: Blood pressure of 80/40 mm Hg Furosemide is a potent diuretic that can lead to a significant depletion of electrolytes, which may lead to side effects such as muscle cramps and an irregular heartbeat. Low blood pressure (hypotension) is a potential side effect of furosemide. Normal blood pressure for adults is typically around 120/80 mm Hg. A blood pressure reading of 80/40 mm Hg is considerably lower than the normal range, indicating hypotension.

Choice D: Serum potassium level of 4.8 mEq/L The normal serum potassium levels range from 3.6 to 5.2 mEq/L. A serum potassium level of 4.8 mEq/L is within the normal range, so the nurse would not need to withhold furosemide for this reason.

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Correct Answer is C

Explanation

Choice A rationale:

Providing samples for sputum cultures every 6 weeks is not a necessary instruction for a client with pulmonary tuberculosis. Sputum cultures are typically performed at specific intervals to monitor the progress of treatment and assess for bacterial resistance. This information is essential for healthcare providers but not for the client's daily care and safety.

Choice B rationale:

Consuming alcohol in moderation while taking antituberculosis medications is not recommended. Alcohol can interact with these medications and reduce their effectiveness. It is essential to advise the client to avoid alcohol completely while on tuberculosis treatment to ensure the best possible outcome.

Choice C rationale:

Wearing a mask while out or around crowds of people is a crucial precaution to prevent the spread of tuberculosis, which is highly contagious. Tuberculosis is transmitted through the air when an infected person coughs or sneezes, making mask-wearing an effective measure to protect both the client and others. This instruction promotes the safety of the client and the community.

Choice D rationale:

Placing tissue soiled with respiratory secretions in a paper bag for later disposal is not a recommended practice. Infectious material should be properly disposed of in biohazard containers or bags designed for infectious waste. This instruction does not follow the standard safety protocols for managing infectious materials and is not in the best interest of the client's health.

A. pH 7.50 and HCO3 31 mm Hg. B. pH 7.30 and HCO3 19 mm Hg. C. pH 7.47 and PaCO2 31 mm Hg. D. pH 7.32 and PaCO2 50 mm Hg.

Correct Answer is C

Explanation

The correct answer is: C.

Choice A reason: A pH of 7.50 and HCO3 of 31 mm Hg suggest a metabolic alkalosis due to the high bicarbonate level. However, during a panic attack, hyperventilation leads to respiratory alkalosis, not metabolic, due to the excessive exhalation of CO2, which is not consistent with this option.

Choice B reason: A pH of 7.30 and HCO3 of 19 mm Hg indicate a metabolic acidosis due to the low bicarbonate level. This is not typically associated with hyperventilation during a panic attack, which usually causes respiratory alkalosis, characterized by a decrease in CO2 levels and an increase in pH.

Choice C reason: A pH of 7.47 and PaCO2 of 31 mm Hg are indicative of respiratory alkalosis, which is expected during hyperventilation as a result of a panic attack. Hyperventilation causes a decrease in carbon dioxide (PaCO2) levels, leading to an increase in pH. The normal ranges for arterial blood gases are: pH 7.35-7.45, PaCO2 35-45 mm Hg, and HCO3 22-26 mEq/L.

Choice D reason: A pH of 7.32 and PaCO2 of 50 mm Hg suggest respiratory acidosis due to the elevated PaCO2 level. This would be more consistent with hypoventilation, which is not the case during a panic attack where hyperventilation occurs.

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A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

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A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide.
For which of the following findings should the nurse withhold the medication?