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 D

Explanation

Helping to position a client for a portable x-ray generally involves physically assisting the client in moving into the appropriate position or adjusting their body as needed. This task can be safely delegated to the UAP as long as they have received proper training on how to safely assist with positioning and have a clear understanding of the specific instructions provided by the radiology department.

Assisting the client to take the beta-blocker involves administering medication, which falls within the scope of nursing practice and requires the nurse's expertise in medication administration and monitoring the client's response.

Transporting the client to the intensive care unit via a stretcher involves moving the client to another unit and may require additional monitoring and coordination of care during the transfer. This task is best performed by the nurse, who can assess the client's stability, ensure appropriate documentation, and communicate effectively with the receiving unit.

Providing discharge-teaching instructions to the client going home requires the nurse to provide information about medications, wound care, follow-up appointments, and other important instructions. This task involves comprehensive education and assessment ofthe client's understanding, and is best performed by the nurse to ensure accurate and complete information is provided.

A. “I have stomach pain every time I eat a big, heavy meal." B. “I don't have any abdominal pain or any type of problems." C. “I have periodic episodes of constipation and then diarrhea." D. “I belch a lot especially when I lay down after eating"

Correct Answer is B

Explanation

Abdominal aortic aneurysms (AAA) often do not present with speciﬁc symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common ﬁnding during the assessment of a client with an abdominal aortic aneurysm.

Let's brieﬂy review the other statements:

"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reﬂux rather than speciﬁcally related to an abdominal aortic aneurysm.

"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.

"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reﬂux or gastroesophageal reﬂux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.

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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 D

Explanation

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Correct Answer is B

Explanation

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