A patient arrives to the emergency department with crackles audible in the bilateral lungs, and 3+ pitting edema to his lower extremities. The provider orders furosemide 40 mg slow IV push to be given one time. Which of the following assessment findings requires the nurse to hold the medication and contact the provider for further instructions?
Sodium 149 mEq/L
Blood pressure 90/53 mmHg
Client is incontinent of urine
Potassium 53 mEq/L
The Correct Answer is B
A. Hypernatremia can indicate dehydration or other electrolyte imbalances. Furosemide can further affect electrolyte balance, especially sodium and potassium. However, this sodium level is only slightly elevated and may not necessarily require immediate action regarding furosemide administration.
B. Furosemide is a diuretic that can further decrease blood pressure due to its effects on fluid volume reduction. Administering it to a patient with already low blood pressure could potentially lead to significant hypotension and compromise perfusion to vital organs.
C. While incontinence itself may not directly contraindicate furosemide administration, it could indicate underlying issues such as bladder dysfunction or fluid overload that need further evaluation. This finding alone would not necessarily require holding the medication, but it warrants further assessment and consideration in the clinical context.
D. Normal serum potassium levels typically range from 3.5-5.0 mEq/L. A level of 5.3 mEq/L indicates hyperkalemia (elevated potassium). While this potassium level is mildly elevated, it would not be a reason on its own to hold furosemide. Monitoring potassium levels closely and potentially adjusting potassium
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
To administer the correct dose of desipramine, which is 150 mg, when the available tablet strength is 100 mg, the nurse would need to give 1.5 tablets.
Correct Answer is C
Explanation
A. During chemotherapy, many patients experience nausea, vomiting, and changes in taste or appetite. Spicy and highly-seasoned foods can exacerbate gastrointestinal symptoms and may not be well tolerated. It's generally recommended to encourage bland, easy-to-digest foods to help maintain adequate nutrition and reduce discomfort.
B. Loperamide is not used to prevent nausea; rather, it is an antidiarrheal medication used to treat diarrhea, which can be a side effect of chemotherapy. Nausea prevention is typically managed with antiemetic medications such as ondansetron, metoclopramide, or others prescribed based on the patient's specific needs and chemotherapy regimen.
C. Pain management is an essential aspect of caring for oncology patients, including those receiving chemotherapy. Cancer and its treatment can cause pain directly or indirectly (such as from procedures or complications). Regular and thorough pain assessments allow for timely intervention and improvement in the client's comfort and quality of life.
D. Chemotherapy medications are typically administered through central venous access devices (e.g., central lines, PICC lines) rather than through peripheral veins. This is because chemotherapy drugs can be vesicants (causing tissue damage if they leak out of the vein) or irritants to smaller peripheral veins.
Using a larger gauge peripheral line (e.g., 18 gauge) is not standard practice for administering chemotherapy due to the potential risks and complications associated with peripheral administration.
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