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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Dysphagia increases the risk of aspiration, especially when swallowing difficulties are present, making it essential to monitor for signs of aspiration.
B. Gastroesophageal reflux disease (GERD) is not directly related to dysphagia from a stroke.
C. Dumping syndrome occurs after certain types of gastric surgery and is not associated with dysphagia post-stroke.
D. Peptic ulcer disease is not a typical complication of dysphagia following a stroke.

A. Dyspnea B. Fever C. Petechiae D. A heart murmur

Correct Answer is A

Explanation

A. Dyspnea can indicate heart failure or embolic events resulting from infective endocarditis, making it a serious complication that warrants attention.
B. Fever is a common symptom of infective endocarditis due to the infection but is not a complication; rather, it is part of the disease process.
C. Petechiae are small red or purple spots that can occur with infective endocarditis but are also not considered a complication, rather a manifestation of the condition.
D. A heart murmur may be present due to valvular damage but is not classified as a complication; it is a common finding in infective endocarditis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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