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

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Headache is a common side effect of nitroglycerin due to its vasodilatory effects, especially in the head. Most headaches associated with nitroglycerin are mild and transient. Patients are generally advised to continue using the medication as prescribed unless the headache is severe or persistent.
B. Nitroglycerin tablets are used for the immediate relief of angina symptoms. If the first tablet does not adequately relieve chest pain within 5 minutes, the patient can take a second tablet. If the pain persists after the second tablet, emergency medical attention should be sought. However, it's important to note that the maximum number of tablets that can be taken within a short period should be specified by the healthcare provider, typically 2 or 3 tablets in 15 to 30 minutes.
C. Nitroglycerin can cause orthostatic hypotension, which is a drop in blood pressure upon standing up. This can lead to dizziness or fainting. Therefore, patients should be advised to stand up slowly after taking nitroglycerin to minimize the risk of falls or injury.
D. Nitroglycerin tablets are sensitive to light, heat, and moisture, which can reduce their effectiveness over time. Therefore, it's recommended to replace nitroglycerin tablets every 3 to 6 months to ensure potency and effectiveness.

A. Petechiae on the oral mucosa. B. Hemoglobin of 14 g/dL. C. Bleeding of the gums after oral care. D. Pain and swelling in one leg.

Correct Answer is D

Explanation

A. Petechiae are tiny, pinpoint, red or purple spots on the skin or mucous membranes, caused by bleeding under the skin. While petechiae can indicate bleeding, they are not specific to HIT and can occur due to various reasons, including low platelet count or coagulation disorders. They do not necessarily indicate thrombotic complications associated with HIT.
B. This hemoglobin level is within the normal range for adults and does not directly correlate with HIT. However, it is important to monitor hemoglobin levels in patients with HIT due to the risk of bleeding and thrombosis.
C. Bleeding gums can occur due to various reasons, including gum disease or thrombocytopenia (low platelet count). In HIT, the concern is not just bleeding but also the paradoxical risk of thrombosis despite low platelet counts. Bleeding from mucosal surfaces can indicate underlying thrombocytopenia but does not specifically highlight the thrombotic risk of HIT.
D. This symptom is concerning for deep vein thrombosis (DVT), which is a thrombotic complication associated with HIT. HIT predisposes patients to thrombosis due to the formation of antibodies against

platelet factor 4/heparin complexes, leading to platelet activation and clot formation. DVT is a serious complication that requires immediate intervention to prevent pulmonary embolism (PE).

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been diagnosed with chronic stable angina and has a new prescription for nitroglycerin tablets. Which statement about this medication should the nurse include in the patient education?

Correct Answer is B

Explanation

A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?

Correct Answer is D

Explanation

A client has been diagnosed with Bell's Palsy. Which statement should the nurse include in the client education?

A female client with multiple sclerosis is being treated with prednisone and the immunomodulator drug interferon B-1a to manage the condition. Which finding is the most important for the nurse to report to the provider?

A nurse on an oncology unit is caring for a client who is receiving intravenous chemotherapy for the treatment of advanced colon cancer. Which of the following items should be included in the plan of care for this client?

A client with Parkinson's disease is started on Levodopa with Carbidopa (Sinemet). What should the nurse include in the patient teaching?

An older adult client who is having difficulty passing urine is found to have elevated levels of prostate-specific antigen (PSA). The nurse understands that this finding indicates which of the following?

The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?

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