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 A

Explanation

Choice A reason: Determining if the client is using an inhaler before exercising is the most immediate and relevant action. Inhalers, particularly bronchodilators, can help prevent exercise-induced bronchoconstriction by relaxing the airway muscles and reducing mucus production.

Choice B reason: Assessing the client for signs and symptoms of upper airway infection is important but may not be directly related to the episodes triggered by exercise. This action might be more appropriate if there are other indications of infection.

Choice C reason: Reviewing the client's routine asthma management prescriptions is a good practice, but it should come after addressing the immediate concern of managing exercise-induced symptoms. Ensuring proper inhaler use can have a more immediate impact.

Choice D reason: Teaching the client to use pursed-lip breathing when episodes occur is useful for managing dyspneal but does not address the prevention of exercise-induced bronchoconstriction as effectively as using an inhaler.

A. Reduces the inflammatory process, improving nerve transmission and function. B. Slows the scarring in the myelin sheath, improving muscle tone and strength. C. Increases the amount of dopamine available for muscles to function correctly. D. Acts as an antiseizure medication, reducing the tremors caused by the disease.

Correct Answer is C

Explanation

Choice A reason: Carbidopa-levodopa does not primarily reduce the inflammatory process. Its main action is related to dopamine synthesis and availability.

Choice B reason: Carbidopa-levodopa does not slow scarring in the myelin sheath. This medication targets dopamine deficiency, not myelin health.

Choice C reason: Carbidopa-levodopa increases the amount of dopamine in the brain. Dopamine is a neurotransmitter that is crucial for motor control. Parkinson's disease is characterized by dopamine deficiency, and this medication helps to replenish dopamine levels, improving muscle function and reducing symptoms like tremors and stiffness.

Choice D reason: Carbidopa-levodopa is not an antiseizure medication. It is specifically used to manage the motor symptoms of Parkinson's disease by addressing dopamine deficiency.

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Naxlex Comprehensive Predictor Exams

A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement?

Correct Answer is A

Explanation

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?

Correct Answer is C

Explanation

A 26-year-old client is admitted to the hospital for treatment of a simple goitre, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis?

The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best indication that the client is adhering to the prescribed diabetic regimen?

The nurse is teaching the client about incentive spirometry in the preoperative unit. Which statement regarding incentive spirometry should the nurse include with preoperative teaching?

A client with chronic venous insufficiency is being discharged from the hospital and plans to return home. Which client statement indicates an understanding of home care instructions?

A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and haemoglobin A1C. Which statement by the client indicates teaching has been effective?

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement?