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?
Blood pressure of 80/40 mm/Hg
Oxygen saturation of 95%
Serum sodium level of 140 mEq/L
Serum potassium level of 4.8 mEq/L
The Correct Answer is A
A. A blood pressure of 80/40 mm/Hg indicates hypotension, which is a contraindication for administering furosemide. The medication can further lower blood pressure and increase the risk of adverse effects.
B. An oxygen saturation of 95% is within normal limits and does not indicate a need to withhold furosemide.
C. A serum sodium level of 140 mEq/L is normal and would not warrant withholding the medication.
D. A serum potassium level of 4.8 mEq/L is also normal and safe for furosemide administration, as the medication may cause potassium loss but does not require withholding if the level is within range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A"}}
Explanation
Assessment Findings and Rationale
1. Ambulation Pattern
Parkinson's Disease: The slow and shuffling gait is characteristic of Parkinson's disease due to muscle rigidity and bradykinesia (slowness of movement). Patients often exhibit a stooped posture and a shuffling gait.
2. Muscle Movements
Parkinson's Disease: Unilateral resting tremors and generalized muscle stiffness are hallmark signs of Parkinson's disease, which affects motor control due to basal ganglia degeneration. As the disease progresses, bilateral tremors and stiffness develop.
3. Speech
Parkinson's Disease: Slow and slurred speech is common in Parkinson's disease as a result of muscle rigidity affecting speech production.
Stroke: Speech difficulties such as slurred speech may also occur in stroke patients due to dysarthria, which arises from motor control deficits.
Multiple Sclerosis: Speech issues, including slurred speech, can also be seen in multiple sclerosis due to neurological involvement and muscle control issues.
4. Orientation Status
Parkinson's Disease: Disorientation to date and time can be seen in later stages of Parkinson's disease as cognitive decline may accompany the motor symptoms.
Stroke: Cognitive deficits, including disorientation, can result from stroke, especially if it affects the areas of the brain responsible for cognition.
Multiple Sclerosis: Orientation issues may also occur in multiple sclerosis as cognitive impairment can be part of the disease process.
5. Facial Rigidity
Parkinson's Disease: Facial rigidity, often described as a "masked face," is a classic symptom of Parkinson's disease, resulting from decreased facial muscle control.
Correct Answer is D
Explanation
A. Nicardipine is a calcium channel blocker primarily used to manage blood pressure but does not directly reduce ICP.
B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.
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