The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Blood glucose level of 175 mg/dl.

Orthostatic systolic BP decrease of 12 mm Hg

Serum potassium level of 3.0 mEq

Current blood pressure (BP) reading of 166/94 mm Hg

Answer and Explanation

The Correct Answer is C

The most important finding to report to the health care provider would be the serum potassium level of 3.0 mEq. This is an extremely low potassium level (normal range is typically 3.5-5.0 mEq/L), which can indicate a potentially life-threatening condition called hypokalemia. Furosemide (Lasix) is a diuretic medication that can cause potassium loss in the urine, and a low potassium level can lead to serious cardiac and muscle abnormalities. It is crucial to report this finding promptly to the health care provider for appropriate intervention and monitoring.

Blood glucose level of 175 mg/dL: While an elevated blood glucose level can be a concern, especially for individuals with diabetes, it is not the most critical finding in this situation. The client's primary concern is hypertension, and the administration of IV furosemide is aimed at managing blood pressure. The elevated blood glucose level should still be addressed and monitored, but it is not as urgent as the low potassium level.

Orthostatic systolic BP decrease of 12 mm Hg: Orthostatic hypotension refers to a significant decrease in blood pressure upon standing up. While it is important to assess and manage orthostatic changes, a decrease of 12 mm Hg in systolic blood pressure alone may not be considered clinically significant. It could be a normal response for some individuals. However, if the client experiences symptoms such as dizziness or lightheadedness upon standing, further evaluation may be necessary. Nonetheless, it is not as urgent as the low potassium level.

Current blood pressure reading of 166/94 mm Hg: While this blood pressure reading indicates hypertension, it is not the most critical finding to report in this situation. The nurse is preparing to administer furosemide (Lasix), which is a medication commonly used to treat hypertension. It is expected that the blood pressure will be high before administering the medication. The goal is to monitor the blood pressure after the administration to assess the effectiveness of the medication.

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Correct Answer is C

Explanation

"I will use a heating pad on my feet at night to increase the circulation.": Using a heating pad on the feet at night is not recommended for clients with peripheral artery disease. The application of heat, such as from a heating pad, can dilate blood vessels and potentially worsen the symptoms of peripheral artery disease. This can lead to reduced blood flow to the affected limbs and increase the risk of complications.

The other client statements demonstrate an understanding of peripheral artery disease management:

"I will avoid long periods of sitting down with my legs crossed over." This statement shows awareness of the importance of maintaining good blood flow and avoiding positions that can restrict circulation.

"I will walk to the point of pain, rest, and walk again for at least 30 minutes." This statement indicates an understanding of the concept of intermittent claudication, a common symptom of peripheral artery disease. Walking until pain occurs, resting, and then resuming walking helps improve circulation and increases walking distance over time.

"I will buy some loose clothes that do not bind across my legs or waist." This statement reflects an awareness of the need to wear loose-fitting clothes that do not constrict blood flow to the legs or waist area.

A. The client reports a headache with pain at level 5 of 10 B. The client has epistaxis after blowing his nose several times C. The client has a urine output of 120 mL over a 4 hours D. The client has a new-onset blurry vision and facial asymmetry

Correct Answer is D

Explanation

The client reports a headache with pain at level 5 of 10.: While a headache can be a symptom of high blood pressure, a pain level of 5 out of 10 alone does not indicate an immediate life-threatening condition. It is important to assess and manage the client's pain, but it may not be the most critical ﬁnding to report in this situation.

The client has epistaxis after blowing his nose several times. : Epistaxis, or a nosebleed, can occur due to high blood pressure, but it is not the most urgent or critical symptom in a hypertensive emergency. While it is essential to address the nosebleed and monitor blood pressure, other symptoms may indicate more severe consequences of uncontrolled high blood pressure.

The client has a urine output of 120 mL over 4 hours.: While decreased urine output can be a concerning sign, it is not the most signiﬁcant ﬁnding to report in a hypertensive emergency. In this scenario, the focus is on acute complications related to high blood pressure, such as organ damage or impending stroke, which require immediate attention.

In summary, the ﬁnding that is most important to report to the healthcare provider in a client with a hypertensive emergency is the presence of new-onset blurry vision and facial asymmetry. These symptoms suggest potential neurological involvement and the need for urgent medical intervention to prevent serious complications like stroke.

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The nurse is preparing to administer IV furosemide (Lasix) to a client with hypertension. What is the most important finding to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

Correct Answer is D

Explanation

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