The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV. Which parameter would the nurse use to best evaluate if the client is responding to this medication?
Serum sodium level is 135 mEq/L (normal 135-145mEq/L)
Respiratory rate of 16/minute
Blood pressure reading of 120/80
Urine output 120 mL one hour following administration
The Correct Answer is B
A. Serum sodium level of 135 mEq/L (normal 135-145mEq/L) - Although important, sodium levels do not directly assess the effectiveness of furosemide in relieving fluid overload.
B. Respiratory rate of 16/minute - A decrease in respiratory rate following the administration of furosemide indicates that the client is improving, as furosemide works to reduce fluid overload and ease breathing.
C. Blood pressure reading of 120/80 - While blood pressure may be influenced by fluid status, it is not the best indicator for the effectiveness of diuretics in this case.
D. Urine output 120 mL one hour following administration - While urine output is important, a single hour’s output may not show the full effectiveness of the diuretic, and output can vary depending on the client’s hydration status.
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Related Questions
Correct Answer is C
Explanation
A. Cryoprecipitate is indicated for low fibrinogen or clotting factor issues, but the client’s primary issue
here is anemia and thrombocytopenia.
B. FFP is used to replace clotting factors. While it could be considered in certain situations, in this case, the primary concern is the severe anemia and thrombocytopenia.
C. This is the most appropriate choice, as the patient has low hemoglobin (anemia) and a very low platelet count, both of which require packed red blood cells and platelets.
D. This combination is typically used for clotting factor issues, not anemia and thrombocytopenia.
Correct Answer is A
Explanation
A. Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B. Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C. Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D. Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.
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