A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?
"I'm going to include more cantaloupe in my diet."
"I will check my pulse before I take the medication."
"I will try to limit foods that contain salt."
"I'll check my blood pressure so it doesn't get too high."
The Correct Answer is A
Choice A reason: Including more cantaloupe in the diet is a good practice for a client on furosemide therapy. Cantaloupe is high in potassium, and furosemide can cause hypokalemia (low potassium levels) as it is a potent diuretic that increases urine production and the excretion of various electrolytes, including potassium. Therefore, consuming foods rich in potassium can help counteract this potential adverse effect.
Choice B reason: Checking the pulse before taking the medication is a general safety measure but does not directly relate to a specific adverse effect of furosemide. While it's important to monitor heart rate, especially in clients with heart failure, this statement does not reflect an understanding of the adverse effects related to furosemide.
Choice C reason: Trying to limit foods that contain salt is an appropriate action for a client with heart failure but is not directly related to an adverse effect of furosemide. Reducing salt intake can help manage heart failure by preventing fluid retention; however, it does not address the specific adverse effects of furosemide therapy.
Choice D reason: Checking blood pressure to ensure it doesn't get too high is important for clients with heart failure but does not indicate an understanding of the adverse effects of furosemide. Furosemide is used to reduce excess fluid in the body, which can lower blood pressure, not increase it. This statement does not reflect an understanding of furosemide's potential to cause electrolyte imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Pressing down on the orbital area of the eye, known as the oculocephalic reflex or 'doll's eye' maneuver, is a method used to assess brainstem function in an unresponsive patient. However, this should be done with caution and is generally avoided if there is a suspicion of a neck injury or increased intracranial pressure.
Choice B reason: Pinching the trapezius muscle is a common method to elicit a response to painful stimuli. It is considered a less invasive and safer initial approach to assess the patient's response to pain without causing harm.
Choice C reason: Using a 25-gauge needle to elicit a response is not a standard practice and can be harmful. It poses a risk of skin puncture and infection, and it is not an appropriate method for assessing a patient's level of consciousness.
Choice D reason: Eliciting a reflex with a reflex hammer is used to assess the deep tendon reflexes, which can provide information about the integrity of the nervous system. However, it is not typically used as a method to elicit a response to painful stimuli in an unresponsive patient.
Correct Answer is B
Explanation
Choice A reason: The Mantoux skin test, also known as the tuberculin skin test, measures the immune response to the tuberculin purified protein derivative (PPD) injected under the skin. An induration of less than 1 mm is not necessarily an indication of non-infectiousness; it may indicate a lack of infection or an inadequate immune response. This test does not reflect the current infectious status as it measures a delayed hypersensitivity reaction and can remain positive for life once someone has been exposed to TB or has received the BCG vaccine.
Choice B reason: Negative sputum cultures for acid-fast bacillus are a strong indication that the client is no longer infectious. Pulmonary tuberculosis is diagnosed and monitored through sputum cultures to detect the presence of Mycobacterium tuberculosis. A series of negative cultures typically indicates that the client is not excreting the bacteria and is, therefore, not contagious.
Choice C reason: While the cessation of coughing up blood-tinged sputum is a positive sign of clinical improvement, it does not conclusively indicate that the client is no longer infectious. The absence of blood in the sputum may simply mean that the damage to lung tissues is healing, but the client could still be harboring and potentially spreading TB bacteria.
Choice D reason: The Quantiferon-TB Gold test is a blood test that measures the immune system's response to TB bacteria. A positive result indicates TB infection, but it does not distinguish between latent infection and active disease, nor does it provide information on infectiousness. The parenthetical "negative" is confusing and should be clarified in the context of the test results.
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