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 128 beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to treatment? (Select all that apply.)
Skin elasticity.
Urinary output.
Oxygen saturation.
Lung sounds.
Pain scale.
Correct Answer : B,C,D
A. Skin elasticity:
Assessing skin elasticity is a measure of hydration status. Improved skin turgor may suggest that the client is responding positively to diuretic therapy by eliminating excess fluid. However, this may not be as immediate or specific as other indicators of response.
B. Urinary output:
Monitoring urinary output is crucial when administering diuretics like furosemide. Increased urine output indicates that the diuretic is promoting the elimination of excess fluid from the body, which is a desired effect in managing heart failure and fluid overload.
C. Oxygen saturation:
Assessing oxygen saturation is important in monitoring respiratory status. Improvement in oxygen saturation levels indicates that the client is responding to interventions aimed at relieving respiratory distress, such as the administration of furosemide.
D. Lung sounds:
Monitoring lung sounds is a key aspect of assessing respiratory function. Reduction in wheezes and crackles suggests that the diuretic is helping to alleviate pulmonary congestion and fluid accumulation in the lungs, contributing to improved respiratory function.
E. Pain scale:
Assessing pain is relevant if the client has reported chest pain or discomfort associated with heart failure. Reduction in pain may indicate improved cardiac function and response to treatment. However, it's important to note that pain assessment may not be as specific to the effects of furosemide as other respiratory and fluid status indicators.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Minimize symptoms by wearing loose, comfortable clothing:
This is the correct answer. Wearing loose, comfortable clothing can help alleviate pressure on the abdomen, reducing the likelihood of exacerbating GERD symptoms.
B. Sleep without pillows at night to maintain neck alignment:
This recommendation is not specifically related to GERD. In fact, elevating the head of the bed or using extra pillows can be helpful in preventing acid reflux during sleep.
C. Adjust food intake to three full meals per day and no snacks:
It is generally recommended for individuals with GERD to have smaller, more frequent meals rather than three large meals. Eating smaller portions can help reduce the likelihood of gastric distention and reflux.
D. Avoid participation in any aerobic exercise programs:
Exercise is generally beneficial for overall health, but intense aerobic exercise immediately after eating may contribute to GERD symptoms. However, this does not mean avoiding all aerobic exercise. It is more appropriate to advise against vigorous exercise immediately after meals.
Correct Answer is D
Explanation
A. Thick skin plaques topped by silvery white scales:
This is a characteristic presentation of psoriasis vulgaris, not an indicator of overexposure to PUVA.
B. Tenderness upon palpation and generalized erythema:
This may be associated with various skin conditions but is not specific to overexposure to PUVA.
C. Brown, rough, greasy, wart-like papules on the face:
This description is not consistent with the expected outcomes or side effects of PUVA treatment.
D. Requires sunglasses because sunlight hurts the eyes.
PUVA treatment involves the use of psoralen, a light-sensitizing medication, followed by exposure to ultraviolet A (UVA) light. Overexposure to PUVA can lead to phototoxic reactions, including eye sensitivity to sunlight (photophobia). If the client requires sunglasses because sunlight hurts the eyes, it suggests that the eyes have been affected by the treatment, and the nurse should intervene to prevent further damage.
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