A patient hospitalized for heart failure exacerbation has been receiving 40 mg furosemide IV twice daily. What statement by the client would alert the nurse to a possible toxic effect of this medication?
My stomach is distended, and I haven't had a bowel movement in 3 days
This IV site seems irritated, it's red and painful
Everything has started sounding muffled, I'm having difficulty hearing
I feel like I've done nothing but urinate since I've been here
The Correct Answer is C
Choice A reason: This choice is incorrect because stomach distension and constipation are not common side effects of furosemide. They may be related to other causes, such as diet, fluid intake, or medication interactions. The nurse should assess the client's abdominal status and bowel habits and provide appropriate interventions, such as increasing fiber, fluids, or laxatives.
Choice B reason: This choice is incorrect because IV site irritation, redness, and pain are not specific side effects of furosemide. They may be caused by other factors, such as infection, infiltration, or phlebitis. The nurse should inspect the IV site and catheter and change them if needed. The nurse should also monitor the client's vital signs and blood cultures for signs of infection.
Choice C reason: This choice is correct because hearing loss or impairment is a rare but serious side effect of furosemide. It can occur due to damage to the inner ear or the auditory nerve. It may be temporary or permanent, depending on the dose and duration of furosemide therapy. The nurse should stop the infusion of furosemide and notify the provider immediately. The nurse should also assess the client's hearing and balance and provide safety measures.
Choice D reason: This choice is incorrect because frequent urination is an expected effect of furosemide. Furosemide is a diuretic that increases the excretion of water and electrolytes through the urine. It helps to reduce fluid overload and edema in clients with heart failure. The nurse should measure and record the client's intake and output and monitor the client's fluid and electrolyte status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Diet cola PO is not an appropriate recommendation for a client with a blood glucose of 30, because diet cola does not contain any sugar and will not raise the blood glucose level. Moreover, the client is lethargic and unable to follow commands, which means they may have difficulty swallowing and may aspirate the liquid.
Choice B reason: Dextrose 50% IV is a potential recommendation for a client with a blood glucose of 30, because it can rapidly increase the blood glucose level and reverse the symptoms of hypoglycemia. However, the nurse is unable to get an IV line started on the client, which makes this option impossible.
Choice C reason: Glucagon IM is the best recommendation for a client with a blood glucose of 30, because it can stimulate the liver to release glucose into the bloodstream and raise the blood glucose level. Glucagon can be given intramuscularly or subcutaneously, which does not require an IV access. Glucagon is usually given as an emergency treatment for severe hypoglycemia when the client is unconscious or unable to swallow.
Choice D reason: Insulin glargine SQ is not an appropriate recommendation for a client with a blood glucose of 30, because insulin glargine is a long-acting insulin that lowers the blood glucose level. Giving insulin to a client with hypoglycemia can worsen their condition and cause coma or death. ⁹
Correct Answer is C
Explanation
Choice A reason: This is incorrect. INR level is a measure of blood clotting time and is not directly affected by digoxin. It is more relevant for patients who are taking anticoagulants, such as warfarin.
Choice B reason: This is incorrect. Temperature is not a priority assessment for a patient receiving digoxin. It may indicate an infection or inflammation, but it is not related to the action or toxicity of digoxin.
Choice C reason: This is correct. Apical heart rate is the priority assessment for a patient receiving digoxin. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, but also slows down the heart rate. The nurse should monitor the apical pulse for one full minute before administering digoxin and withhold the dose if the pulse is below 60 beats per minute for adults or below the age-specific normal range for children. A low or irregular pulse may indicate digoxin toxicity, which can be life-threatening.
Choice D reason: This is incorrect. Blood pressure is not a priority assessment for a patient receiving digoxin. Digoxin does not have a direct effect on blood pressure, although it may improve the cardiac output and reduce the fluid retention in patients with heart failure. Blood pressure should be monitored regularly, but it is not as critical as the apical heart rate.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.