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 C
Explanation
A. The soles of the feet are not typically assessed for cyanosis because they are not a reliable indicator of central cyanosis. Cyanosis is best evaluated in areas where mucous membranes are visible.
B. Similar to the soles of the feet, the palms of the hands are not a reliable indicator of central cyanosis. Cyanosis is not typically visible on the palms unless there are severe systemic circulation issues.
C. The oral mucosa (inside the mouth) is a reliable area to assess for central cyanosis. The nurse can inspect the lips, tongue, and buccal mucosa for a bluish discoloration, which indicates decreased arterial oxygen saturation.
D. The nail beds are also a reliable indicator of central cyanosis. The nurse can assess the color of the nail beds and look for bluish discoloration, which can be more apparent in darker-skinned individuals compared to the lips and oral mucosa.
Correct Answer is D
Explanation
A. Defibrillation is used to treat life-threatening arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia, where the heart is in a chaotic rhythm without an effective contraction.
B. This procedure is performed to relieve significant blockages in coronary arteries that are causing myocardial ischemia or infarction. While coronary artery disease can contribute to cardiac issues, it is not the primary intervention for treating atrial fibrillation with a rapid ventricular response and associated symptoms like dizziness, shortness of breath, and hypotension.
C. While an echocardiogram may be useful in assessing the overall cardiac function and structure, it is not an immediate intervention for the acute management of atrial fibrillation with a rapid ventricular response and unstable symptoms.
D. Synchronized cardioversion is a procedure used to convert certain types of rapid arrhythmias, including atrial fibrillation, to a normal sinus rhythm by delivering a synchronized electrical shock to the heart at a specific point in the cardiac cycle.
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