In the context of a patient undergoing IV furosemide (Lasix) treatment for hypertension, which observation is most crucial to communicate to the healthcare provider?

Choice A rationale
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight may be experiencing deep vein thrombosis (DVT), a condition that can lead to serious complications such as pulmonary embolism if not treated. However, DVT is not immediately life-threatening in most cases.
Choice B rationale
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools is likely experiencing gastrointestinal bleeding, a common side effect of anticoagulant therapy. This can lead to severe blood loss, anemia, and hypovolemic shock, which can be life-threatening if not promptly addressed. Therefore, this patient should be prioritized for assessment.
Choice C rationale
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse likely has peripheral artery disease and an infection that could lead to sepsis if not treated. However, while this condition needs medical attention, it is not as immediately life-threatening as gastrointestinal bleeding.
Choice D rationale
A 50-year-old patient reporting sudden, severe upper back pain could be experiencing a number of conditions, ranging from musculoskeletal strain to aortic dissection. While an aortic dissection is a medical emergency, without additional symptoms such as chest pain, shortness of breath, or loss of consciousness, this patient is not the highest priority.

Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice B rationale
Cardioverting the client with a biphasic defibrillator is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.
Choice C rationale
The first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern is to assess the patient’s airway, breathing, and circulation.
Choice D rationale
Administering an amiodarone bolus followed by a drip is not the first action a nurse should take when a patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern.