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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
"Have you recently taken any antihistamines?": This question is not directly related to the client's high blood pressure. Antihistamines are medications used to treat allergic reactions and have minimal impact on blood pressure.
"Have there been recent stressful events in your life?": Stress can affect blood pressure levels, so this question is relevant. Stressful events can trigger temporary increases in blood pressure. However, it is important to note that consistently high blood pressure readings require medical attention beyond stress management alone.
"Did you take any acetaminophen today?": Acetaminophen (also known as paracetamol) is a pain reliever and fever reducer. It does not have a significant impact on blood pressure levels. Therefore, this question may not directly address the issue of high blood pressure.
"Have you consistently taken your medications?" : This question is the most appropriate follow-up question for a client with a history of high blood pressure. It addresses medication adherence, which is crucial for managing hypertension. The client's blood pressure reading of 210/106 mm Hg suggests that their current medication regimen may not be effectively controlling their blood pressure. Assessing medication consistency will help determine if the elevated blood pressure is due to non-adherence or if a change in medication is required.
Correct Answer is A
Explanation
Having a permanent cardiac pacemaker is a significant factor that needs to be communicated to the health care provider before undergoing an MRI. Magnetic resonance imaging (MRI) uses powerful magnets, radio waves, and a computer to create detailed images of the body. The presence of a cardiac pacemaker can be a contraindication for undergoing an MRI because the strong magnetic field can potentially interfere with the functioning of the pacemaker or cause it to malfunction. It is crucial to assess the compatibility of the pacemaker with the MRI machine and to take appropriate precautions or make necessary arrangements to ensure the safety of the client during the procedure.
While the other pieces of information provided may be relevant to the client's overall health and medical history, they may not have a direct impact on the safety or feasibility of undergoing an MRI.
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