The health care provider has written the following orders for a client with bounding peripheral pulses, weight gain of 2 lb., pitting edema, and moist crackles bilaterally. Which order will the nurse complete first?
Metoprolol 50 mg. PO daily.
Maintain accurate intake and output records.
Furosemide (Lasix) 40 mg IV push.
Encourage fluid intake more than 2000 mL/day
The Correct Answer is C
The client's symptoms of bounding peripheral pulses, weight gain, pitting edema, and moist crackles bilaterally suggest fluid volume overload or fluid retention. Furosemide (Lasix) is a loop diuretic that helps to promote diuresis and reduce fluid volume. Administering the medication promptly can help address the client's symptoms and alleviate the fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Bowel sounds are the result of muscular contractions in the intestines, indicating the movement of food, fluids, and gas through the gastrointestinal tract. After surgery, the normal function of the intestines, including peristalsis, may be temporarily impaired. As the intestines recover and regain their normal motility, bowel sounds will become audible.
The return of bowel sounds is an encouraging sign that the gastrointestinal system is starting to function again. It indicates that peristaltic activity has resumed and that the intestines are moving and processing the contents within. This is an essential step in the postoperative recovery process, as it indicates the return of normal gastrointestinal function and can lead to the resumption of oral intake and passage of stool.
While the other options may also be associated with the return of GI function, such as feeling hungry or passing flatus or stool, the presence of bowel sounds is a more reliable and direct assessment finding that indicates the resumption of peristaltic activity.
Correct Answer is D
Explanation
Aspiration refers to the inhalation of gastric contents or other substances into the respiratory tract. During surgery, when the patient is under general anesthesia, the protective airway reflexes may be suppressed, increasing the risk of aspiration. If stomach contents enter the lungs, it can lead to aspiration pneumonia, respiratory distress, and other complications.
While myocardial infarction (MI), hernia, and cerebral vascular accident (CVA) are possible complications that can occur during surgery, they are not specifically related to airway issues.
MI is a cardiac event involving the blood supply to the heart muscle, hernia refers to the protrusion of an organ or tissue through an abnormal opening, and CVA refers to a disruption of blood flow to the brain. These complications can have various causes but are not directly related to the airway during surgery.
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