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

Answer and Explanation

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

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Correct Answer is A

Explanation

A. This option is appropriate because the client's low white blood cell count (3,100/mm³) suggests they are at risk for infection due to chemotherapy-induced immunosuppression. Using an electric shaver reduces the risk of cuts and nicks that could potentially lead to infections.

B. This option is not necessary based on the client's current lab results. Negative pressure isolation rooms are typically reserved for clients with severely compromised immune systems, such as those with very low neutrophil counts (neutropenia). A white blood cell count of 3,100/mm³ is within a range where standard precautions are usually sufficient.
C. This option addresses food safety precautions for clients with neutropenia (low white blood cell count). Raw vegetables, including salads, have a higher risk of harboring bacteria that could cause infections. Therefore, cooked vegetables are safer for clients with compromised immune systems.
D. This option is appropriate because chemotherapy-induced thrombocytopenia (low platelet count of 280,000/mm³) increases the risk of bleeding. Forceful blowing of the nose can traumatize the nasal mucosa and increase the risk of nosebleeds. Dabbing the nose gently is a safer method to avoid nosebleeds.

A. Treats hyperlipidemia to reduce the risk of new plaques B. Prevents the formation of clots to reduce the risk of stroke C. Prevents vagal stimulation to reduce e risk of dysrhythmias D. Removes excess sodium to reduce the risk of hypertension

Correct Answer is C

Explanation

A. This statement refers to medications like statins (e.g., rosuvastatin, atorvastatin) which are used to lower cholesterol levels and reduce the risk of atherosclerosis progression. Docusate sodium does not treat hyperlipidemia or affect plaque formation directly.
B. This refers to anticoagulant medications (e.g., heparin, warfarin, direct oral anticoagulants) which are used to prevent clot formation and reduce the risk of thromboembolic events such as stroke. Docusate sodium does not have anticoagulant properties.
C. After a myocardial infarction (MI), especially in the early recovery phase, vagal stimulation can exacerbate bradycardia or contribute to dysrhythmias. Stool softeners like docusate sodium help prevent constipation, which can stimulate the vagus nerve during straining, potentially leading to vagally mediated dysrhythmias such as bradycardia or atrioventricular blocks.
D. Diuretics (e.g., furosemide, hydrochlorothiazide) are used to reduce fluid retention and lower blood pressure by increasing urine output. Docusate sodium does not remove excess sodium or affect blood pressure regulation.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving chemotherapy. The client's most recent lab results show a white blood cell count of 3,100/mm3, and a platelet count of 280,000/mm3. Based on these lab results, which nursing action is appropriate for this client?

Correct Answer is A

Explanation

A nurse is discussing the use of docusate sodium (Colace) with a client who is recovering from a non-ST elevation myocardial infarction (NSTEMI). What is the rationale for administering this medication during the recovery from a myocardial infarction?

Correct Answer is C

Explanation

A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?

Which pathophysiologic change is found in the brain tissue of people who have Alzheimer's disease?

A client who has been diagnosed with chronic stable angina is placed on multiple medications to manage the condition. The nurse understands that the client is receiving rosuvastatin for which reason?

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