The nurse is admitting a 69-year-old male patient with acute heart failure. The physician has ordered furosemide 80 mg IV stat, digoxin 0.25 mg PO, and potassium chloride 20 mEq PO now. Which assessment finding is most indicative of an ineffective response 2 hours after the administration of all the medications?
Pulse oximetry 96%.
Heart rate of 77, regular.
Trace bilateral ankle edema.
Urine output 60 mL.
The Correct Answer is D
The correct answer is d. Urine output 60 mL.
Choice A reason: A pulse oximetry reading of 96% is within normal limits and does not indicate an ineffective response to the medications.
Choice B reason: A heart rate of 77, regular, is also within normal limits and does not suggest an ineffective response.
Choice C reason: Trace bilateral ankle edema may persist even after effective treatment due to residual effects of heart failure.
Choice D reason: A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response acknowledges the patient's feelings and invites further discussion, which can help the nurse understand the patient's concerns and provide appropriate support.
Choice B reason: Asking about specific challenges can be helpful, but it might be too direct for an initial response when the patient is expressing a general sense of being overwhelmed.
Choice C reason: While it's true that the healthcare team will provide support, this response may not address the patient's immediate emotional needs and concerns.
Choice D reason: This response might seem dismissive of the patient's concerns and does not acknowledge the difficulty of adjusting to a chronic illness like Parkinson's disease.
Correct Answer is D
Explanation
Choice A reason: Petechiae and bruising could be related to low platelet counts or clotting issues, but they are not directly indicated by the provided lab values.
Choice B reason: Jaundice and pruritus are symptoms associated with liver disease but are not specifically indicated by the lab values provided.
Choice C reason: Dyspnea and fatigue could be symptoms of many conditions, including liver disease, but they are not directly indicated by the lab values provided.
Choice D reason: Asterixis, a flapping tremor of the hands, and confusion are signs of hepatic encephalopathy, which can be associated with elevated serum ammonia levels, as indicated by the lab results.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.