The nurse is administering Furosemide 40 mg PO to a client with peripheral edema. Which method should the nurse use to best evaluate the client's response to this medication?

Monitor serum sodium levels

Auscultate breath sounds

Perform daily weights

Take the blood pressure

Answer and Explanation

The Correct Answer is C

A. Monitor serum sodium levels: While serum sodium levels can provide some information about fluid balance, they are not the most direct indicator of the effectiveness of furosemide
in reducing peripheral edema.

B. Auscultate breath sounds: This is important for monitoring potential fluid overload or pulmonary complications, but it does not directly assess the reduction of peripheral edema, which is the primary concern with furosemide administration.

C. Perform daily weights: This method is the best way to evaluate the client's response to furosemide. Daily weights can provide a clear indication of fluid status and changes in peripheral edema, as a decrease in weight typically reflects effective diuresis.
D. Take the blood pressure: While monitoring blood pressure is important, especially in clients receiving diuretics, it does not specifically measure the effectiveness of the medication in addressing peripheral edema.

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Correct Answer is C

Explanation

A. "I should continue to read the labels of foods I select in the grocery store.": This statement is appropriate as reading labels helps the client avoid high sodium and unhealthy fats, which can negatively impact blood pressure.

B. "When I get out of bed in the morning, I should first sit for a few minutes and then stand.": This statement reflects a good understanding of managing potential orthostatic hypotension, which can occur with antihypertensive medications. It indicates awareness of the need to rise slowly to prevent dizziness.

C. "I will be able to stop my anti-hypertensive medication when my blood pressure is normal.": This statement indicates a need for clarification. Many patients believe that once their blood pressure is normal, they can discontinue medication, but hypertension is often a chronic condition that requires ongoing management to maintain blood pressure control.

D. "Keeping my blood pressure under control reduces my risk for a heart attack.": This statement is accurate and demonstrates an understanding of the importance of hypertension management in reducing cardiovascular risk.

A. express no complaints of chest discomfort or shortness of breath. B. discuss which lifestyle modifications will be necessary to maintain health. C. have clear breath sounds bilaterally upon auscultation. D. have a urinary output of greater than 30 ml per hour for 24 hours.

Correct Answer is A

Explanation

A) Express no complaints of chest discomfort or shortness of breath: This outcome directly relates to the goal of improving tissue perfusion. Chest discomfort and shortness of breath can indicate inadequate perfusion, particularly in a client with coronary artery disease. By achieving this outcome, the nurse can assess that tissue perfusion is sufficient and the client is stable.

B) Discuss which lifestyle modifications will be necessary to maintain health: While this is an important aspect of ongoing care and management for coronary artery disease, it does not directly address the immediate concern of impaired tissue perfusion. The priority is to ensure the client is currently experiencing effective perfusion rather than just planning for future health modifications.

C) Have clear breath sounds bilaterally upon auscultation: Clear breath sounds are a positive indicator of pulmonary function but do not directly measure tissue perfusion related to coronary artery disease. While this is important for overall health, it does not specifically target the issue of impaired perfusion in cardiac tissue.

D) Have a urinary output of greater than 30 ml per hour for 24 hours: While adequate urinary output can be a sign of good kidney perfusion and overall fluid balance, it is not a direct indicator of cardiac tissue perfusion. The priority in this scenario is more closely tied to the client’s cardiac status and symptoms related to coronary artery disease.

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The nurse is administering Furosemide 40 mg PO to a client with peripheral edema. Which method should the nurse use to best evaluate the client's response to this medication?

Nursing Test Bank

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Correct Answer is A

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