A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment?

Rationale for A: Decreased reflexes can indicate hypokalemia, an adverse effect of loop diuretics. Loop diuretics increase the excretion of potassium, which can lead to low potassium levels, manifesting as muscle weakness and diminished reflexes.

Rationale for B: Weight gain, especially in the context of heart failure, suggests fluid retention rather than an adverse effect of a loop diuretic, which is expected to reduce fluid retention by promoting diuresis.

Rationale for C: Increased urinary output is an expected effect of loop diuretics, as they are used to remove excess fluid. This would not be considered an adverse effect unless it leads to dehydration or electrolyte imbalances.

Rationale for D: Jugular vein distention indicates fluid overload, which would suggest that the diuretic is not effective or that the heart failure is worsening. It is not a direct adverse effect of the medication itself.

A.

A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.

B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.

C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.

D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.