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 D

Explanation

Choice A rationale:

Cool, clammy skin is not a typical manifestation of hypernatremia (high sodium levels). Hypernatremia is characterized by an excess of sodium in the blood, which typically leads to symptoms such as thirst, dry mucous membranes, and decreased skin turgor. Cool, clammy skin is more often associated with conditions like shock or hypoglycemia.

Choice B rationale:

Increased salivation is not a common manifestation of hypernatremia. Instead, hypernatremia often leads to signs of dehydration, including dry mouth and decreased salivation.

Choice C rationale:

Hypertension is not a direct manifestation of hypernatremia. Hypernatremia can cause increased blood pressure, but it is not one of the typical clinical signs of hypernatremia. Hypertension is more commonly associated with conditions like high sodium intake, kidney disease, or primary hypertension.

Choice D rationale:

A decreased level of consciousness is a significant manifestation of hypernatremia. Elevated sodium levels in the blood can lead to cellular dehydration, affecting brain cells and resulting in neurological symptoms such as confusion, lethargy, and decreased consciousness. Severe hypernatremia can even lead to seizures and coma. .

A. Elevate the head of the bed to a 45-degree angle. B. Apply the client's positive airway pressure device. C. Lift and lock the side rails in place. D. Remove dentures or other oral appliances.

Correct Answer is B

Explanation

Choice A rationale:
Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA) to help prevent airway obstruction during sleep. However, this should not be the nurse's immediate priority before leaving the client. Ensuring the client's positive airway pressure (PAP) device is properly applied is more crucial.
Choice C rationale:
While locking the side rails in place is generally essential for safety, it is not the most critical intervention for a client with OSA and urination issues. Ensuring proper use of the PAP device is a higher priority.
Choice D rationale:
Removing dentures or other oral appliances is important for preventing airway obstruction in clients with OSA, but it should not take precedence over ensuring the use of the PAP device. The nurse should address the immediate respiratory needs of the client.

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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?