An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?
A coronary artery bypass procedure was performed in 1995.
Suffered with depression following death of spouse in 1999.
Digoxin and furosemide daily since 1996.
A Colonoscopy was performed for routine screening six months ago.
The Correct Answer is C
Digoxin is a medication commonly used to treat heart failure by strengthening the heart's contractions and slowing down the heart rate. However, it can also cause nausea, vomiting, and loss of appetite, especially when levels in the body are too high. Furosemide is a diuretic medication that helps to remove excess fluid from the body, which is often necessary in heart failure. However, it can also cause electrolyte imbalances, such as low potassium levels, which can contribute to nausea and vomiting.
Therefore, in a client with heart failure who is experiencing these symptoms, it is important to assess their medication regimen, including dosages and serum levels, to ensure that they are not experiencing medication side effects or toxicity.
Adjustments may need to be made to the client's medication regimen to manage symptoms effectively and prevent further complications. Options (a), (b), and (d) do not have as direct a correlation to the current symptoms and would not have the same level of significance when planning care for this client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A total calcium level of 14 mg/dL (3.5 mmol/L) is higher than the normal range of 2.2 to 2.6 millimoles per liter (mmol/L)1. Calcitriol and calcium carbonate are both medications used to increase calcium levels in the blood2. Since the client’s calcium level is already high, it would be important for the nurse to hold both medications and contact the healthcare provider for further instructions.
Correct Answer is B
Explanation
Lactulose is a medication commonly used in the management of hepatic encephalopathy. It works by reducing the absorption of ammonia in the gut, which is a toxin that can accumulate in the blood in patients with liver dysfunction.
Monitoring serum electrolytes and ammonia levels can help the nurse evaluate the effectiveness of lactulose therapy. Elevated ammonia levels can indicate that the medication is not effectively reducing ammonia absorption and may require adjustment in dose or frequency. Additionally, monitoring electrolyte levels can help detect any imbalances that may occur because of lactulose therapy.
Fingerstick glucose levels (option A) are not relevant to evaluating the therapeutic response of lactulose in hepatic encephalopathy.
Stool color and character (option C) may be monitored to assess the side effects of lactulose, such as diarrhea, but are not the best assessments to evaluate therapeutic response.
Serum hepatic enzymes (option D) may be useful in assessing the severity of liver disease but are not the best assessment to evaluate the therapeutic response of lactulose in hepatic encephalopathy.
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