An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate of 128 beats/minute and irregular, respirations of 38 breaths/minute, blood pressure of 168/100 mm Hg, and oxygen saturation of 90% on room air. Wheezes and crackles are noted throughout bilateral lung fields. An hour after the administration of furosemide 60 mg IV push (IVP), which assessments should the nurse obtain to determine the client's response to treatment? Select all that apply.

Skin elasticity.

Pain scale.

Lung sounds.

Oxygen saturation.

Urinary output.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Skin elasticity is not an immediate indicator of the client's response to diuretic treatment. It is more commonly used to assess hydration status and overall skin condition rather than the effectiveness of a diuretic.

Choice B reason: Pain scale is important for assessing the client's comfort level, but it does not directly measure the effectiveness of furosemide in improving respiratory status and reducing fluid overload.

Choice C reason: Lung sounds should be assessed to determine if there is an improvement in the client's respiratory status after the administration of furosemide. Reduction in wheezes and crackles would indicate decreased fluid in the lungs and improved breathing.

Choice D reason: Oxygen saturation is crucial to monitor as it provides information on the client's oxygenation status. An improvement in oxygen saturation levels indicates effective relief of pulmonary congestion and better gas exchange after the diuretic treatment.

Choice E reason: Urinary output is a direct measure of the effectiveness of furosemide, as it promotes diuresis to remove excess fluid from the body. Increased urinary output indicates that the medication is working to reduce fluid overload.

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Correct Answer is D

Explanation

Choice A reason: Administering insulin per sliding scale is typically based on blood glucose levels, not just the client's report of hunger. Since the client has already received insulin, providing more insulin without knowing the current blood glucose level could cause hypoglycaemia.

Choice B reason: Starting hourly blood glucose monitoring might be necessary in certain situations, but the immediate need is to address the client's hunger, which could be a sign of impending hypoglycaemia. Addressing the hunger first is more urgent.

Choice C reason: Initiating an IV bolus of 0.9% sodium chloride is not indicated in this scenario. This intervention is typically used for dehydration or other fluid imbalances, not for managing hunger or blood glucose levels directly.

Choice D reason: Providing a snack of cheese and crackers is the most appropriate action. The client's report of hunger after receiving insulin and eating only half of breakfast suggests they might be at risk for hypoglycaemia. A snack will help stabilize their blood glucose levels and prevent hypoglycaemia.

A. Serum potassium 5.0 me/L (5.0 mmol/L), serum sodium 138 me/L (138 mmol/L). B. Serum potassium 4.5 me/L (4.5 mmol/L), serum sodium 140 me/L (140 mmol/L). C. Serum potassium 3.5 me/L (3.5 mmol/L), serum sodium 142 me/L (142 mmol/L). D. Serum potassium 3.0 me/L (3.0 mmol/L), serum sodium 149 me/L (149 mmol/L).

Correct Answer is D

Explanation

Choice A reason: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

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Naxlex Comprehensive Predictor Exams

The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?

Correct Answer is D

Explanation

A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?

Correct Answer is D

Explanation

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