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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the client to discontinue the dose of acetylsalicylic acid (aspirin) 2 weeks before surgery. Aspirin is an antiplatelet medication that can increase the risk of bleeding during and after surgery. Discontinuing it before surgery helps reduce the risk of excessive bleeding during the procedure. The recommended time frame for discontinuation may vary based on the patient's surgical procedure and the surgeon's preferences. However, 2 weeks is a common guideline to ensure that the antiplatelet effects of aspirin have diminished.
Choice B rationale:
Decreasing the dose by half 2 weeks before surgery may not be sufficient to minimize the risk of bleeding associated with aspirin. It is generally recommended to discontinue the medication completely to ensure that the antiplatelet effect has worn off.
Choice C rationale:
Taking the originally prescribed dose of aspirin the week of surgery is not advisable because it can increase the risk of bleeding during the surgical procedure. It is important to discontinue aspirin well before the surgery.
Choice D rationale:
Doubling the dose of aspirin the week of surgery is contraindicated as it can significantly increase the risk of bleeding. This choice is not recommended in the context of preoperative management.
Correct Answer is D
Explanation
Choice A rationale:
Skipping coffee on the morning of the exercise ECG stress test is a good idea as caffeine can affect heart rate and blood pressure, but it doesn't necessarily indicate the need for further instructions.
Choice B rationale:
Getting 8 hours of sleep the night before the test is a positive choice and promotes overall well-being, but it is not a specific indicator of needing further instructions for the test.
Choice C rationale:
Not smoking before the test is an appropriate action, as smoking can also affect heart rate and blood pressure during the test. However, it does not indicate a need for further instructions.
Choice D rationale:
Expecting to feel chest pain during an exercise ECG stress test is not correct and indicates a need for further instructions. Chest pain during the test can be a sign of cardiovascular issues and should be reported immediately.
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