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

Answer and Explanation

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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Correct Answer is D

Explanation

A. This would be concerning, but it is not the correct choice. If a pacemaker is functioning abnormally, it would require an assessment and troubleshooting, not simply a routine rhythm.
B. This is typical for biventricular pacemakers used in heart failure patients, but it would not apply to a patient with a standard pacemaker unless specified. A recent pacemaker placement does not necessarily indicate biventricular pacing.
C. This is correct if only the atrium is paced; however, in the case of a typical pacemaker like DDD (dual- chamber pacemaker), both the atrium and ventricle are paced.
D. This is correct for dual-chamber pacemakers (like DDD), which pace both the atrium and the ventricle to coordinate the heart's rhythm.

A. prepare to place the client in a single room. B. ask the client if they wish to speak to a spiritual advisor. C. explore the possibility of suicidal thoughts with the client. D. explain to the client that they will not die for a long time.

Correct Answer is C

Explanation

A. While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B. This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C. When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D. While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the client with a recent pacemaker placement. The client's monitor is displaying what type of rhythm?

Correct Answer is D

Explanation

The physician has just informed a client with advanced heart failure that a left ventricular assist device (LVAD) will be needed. The client is crying and says to the nurse, "I just know that I am going to die. What's the point of treatment?" The priority nursing action is to:

Correct Answer is C

Explanation

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