A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Expect some swelling in the hands and feet.

Take the medication at bedtime.

Eat foods that contain plenty of potassium.

Take aspirin if headaches develop.

Answer and Explanation

The Correct Answer is C

A: Expecting some swelling in the hands and feet is incorrect. Furosemide is a diuretic used to reduce fluid buildup, so swelling should decrease, not increase.
B: Taking the medication at bedtime is not recommended because furosemide increases urine output, which can disrupt sleep. It is better to take it in the morning.
C: Eating foods that contain plenty of potassium is important because furosemide can cause potassium loss. Consuming potassium-rich foods helps maintain electrolyte balance and prevent hypokalemia.
D: Taking aspirin if headaches develop is not related to the use of furosemide. The nurse should address headache management separately and ensure the client understands the specific instructions for furosemide use.

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Correct Answer is C

Explanation

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

A. Blood pressure 178/90 mm Hg B. Jugular vein distention C. Heart rate 50 D. Skin tenting present

Correct Answer is D

Explanation

A: Blood pressure of 178/90 mm Hg indicates hypertension, not dehydration. Dehydration typically leads to low blood pressure due to reduced blood volume.

B: Jugular vein distention is associated with fluid overload or heart failure, not dehydration. Dehydration usually results in flat neck veins.

C: A heart rate of 50 beats per minute is bradycardia and is not typically associated with dehydration. Dehydration often causes an increased heart rate (tachycardia) as the body tries to maintain adequate circulation.

D: Skin tenting present is a classic sign of dehydration. When the skin is pinched and does not return to its normal position quickly, it indicates a lack of fluid in the tissues.

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A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Nursing Test Bank

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