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 A
Explanation
The lower esophageal sphincter (LES) is a muscular ring located between the esophagus and stomach. Its function is to prevent the backflow of stomach acid and contents into the esophagus. In GERD, the LES becomes weak or relaxed, allowing stomach acid to flow back up into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest pain.
Correct Answer is D
Explanation
Hip spica casts are typically used to immobilize the hip joint and are often used in the management of hip dysplasia or after surgery. These casts can cause restricted mobility and limit blood flow to the legs and feet, which can lead to complications such as swelling, decreased circulation, or pressure sores.
Checking capillary refill in the toes is a critical nursing intervention to assess for the presence of adequate circulation and blood flow to the affected limb. If capillary refill is slow or absent, it may indicate compromised circulation and require immediate intervention to prevent further complications.
Palpating a brachial pulse, assessing bilateral radial pulses, or auscultating the heart rate apically are not the priority nursing actions for an infant with a hip spica cast. While monitoring vital signs and circulation are important components of nursing care, the priority at this stage is to assess and manage the immediate postoperative needs of the patient, including monitoring for potential complications related to the hip spica cast.
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