Exhibits
Review the exhibits and click to mark whether each assessment finding represents a therapeutic result of the furosemide administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.
- Potassium 3.1 mEq/L
- Prothrombin time/International normalized ratio (INR) 2.2
- Urine output: 600 mL
Potassium 3.1 mEq/L
Prothrombin time/INR 2.2
Urine output: 600 mL
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}
Based on the question and the known effects of furosemide, here’s how each assessment finding can be categorized:
- Potassium 3.1 mEq/L: This is a non-therapeutic side effect. Furosemide is a diuretic that increases the excretion of water, sodium, and potassium from the body. This can lead to hypokalemia, or low potassium levels.
- Prothrombin time/INR 2.2: This is likely an unrelated finding. Furosemide does not typically affect prothrombin time or INR. However, the patient is also taking warfarin, which is an anticoagulant known to increase INR.
- Urine output: 600 mL: This is a therapeutic result. Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.
Choice B rationale
Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.
Choice C rationale
Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.
Choice D rationale
Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
The assessment findings that require immediate follow up by the nurse are: The client has mild subcostal retractions. This could indicate that she is using accessory muscles to breathe, which is a sign of respiratory distress. The client is sitting in an upright position. This is a common position for people who are having difficulty breathing because it allows for maximum expansion of the lungs. Wheezes are noted throughout the lung fields. Wheezing can be a sign of an obstructive process such as asthma. The client is pale. Paleness can be a sign of decreased oxygenation. Her heart rate is 122 beats/minute, which is above the normal range and can indicate that her body is working harder to get oxygen. Her oxygen saturation is 91% on room air. Normal oxygen saturation is generally 95% or higher, so this could indicate that she is not getting enough oxygen.
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