The nurse obtains a prescription for furosemide 40 mg IV for a client who has pulmonary congestion as the result of fluid volume overload. The nurse assesses the vital signs to be T-98.6, P-110, RR-24 and BP-90/60. What is the most appropriate action at this time?
Withhold the dose and reassess the blood pressure in 30 minutes.
Call the healthcare provider to obtain an order for oral furosemide.
Administer the medication and notify the healthcare provider of the blood pressure.
Administer the dose and continue to monitor the vital signs.
The nurse obtains a prescription for furosemide 40 mg IV for a client who has pulmonary congestion as the result of fluid volume overload. The nurse assesses the vital signs to be T-98.6, P-110, RR-24 and BP-90/60. What is the most appropriate action at this time?
The Correct Answer is C
Choice A reason: Withholding the dose and reassessing the blood pressure in 30 minutes is not the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Delaying the administration of furosemide may worsen the client's condition and increase the risk of complications, such as pulmonary edema or heart failure.
Choice B reason: Calling the healthcare provider to obtain an order for oral furosemide is not the most appropriate action at this time. Oral furosemide is a tablet that is swallowed and absorbed by the digestive system. ¹ It takes longer to act than intravenous (IV) furosemide, which is injected directly into the bloodstream. ¹ The client has pulmonary congestion, which requires immediate treatment to relieve the fluid accumulation in the lungs. Switching to oral furosemide may delay the therapeutic effect and compromise the client's outcome.
Choice C reason: Administering the medication and notifying the healthcare provider of the blood pressure is the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Administering IV furosemide can help remove the excess fluid from the lungs and improve the client's breathing and oxygenation. However, furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ The client already has low blood pressure, which can cause dizziness, fainting, or shock. The nurse should notify the healthcare provider of the blood pressure and monitor the client for any signs of hypotension or adverse reactions.
Choice D reason: Administering the dose and continuing to monitor the vital signs is not the most appropriate action at this time. Furosemide is a drug that reduces fluid retention and swelling by increasing the urine output. ¹ The client has pulmonary congestion, which means that there is excess fluid in the lungs, causing difficulty breathing and low oxygen levels. ² Administering IV furosemide can help remove the excess fluid from the lungs and improve the client's breathing and oxygenation. However, furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ The client already has low blood pressure, which can cause dizziness, fainting, or shock. The nurse should not only monitor the vital signs, but also notify the healthcare provider of the blood pressure and report any changes or concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The Schilling test is not used to diagnose G6PD anemia, which is a genetic disorder that causes red blood cells to break down when exposed to certain substances. The Schilling test is used to measure how well the body absorbs vitamin B12 from the intestine. ¹²
Choice B reason: The Schilling test does not require the patient to be NPO (nothing by mouth) for 12 hours prior to the test. The patient can drink water, but should avoid food for 8 hours before the test. ²
Choice C reason: The Schilling test is a 24-hour urine specimen collection test. The patient is given a dose of radioactive vitamin B12 by mouth and another dose of nonradioactive vitamin B12 by injection. The urine is collected for 24 hours to measure how much of the radioactive vitamin B12 is excreted. This indicates how well the body absorbs vitamin B12 from the intestine. ¹²
Choice D reason: The Schilling test does not entail administration of methylcellulose prior to the test. Methylcellulose is a type of laxative that can interfere with the absorption of vitamin B12. The patient should avoid taking any laxatives, antacids, or antibiotics before the test. ²³
Correct Answer is B
Explanation
Choice A reason: It is not the best intervention to exclude the family from the exercise program. Family involvement can provide support, motivation, and accountability for the client. Family members can also participate in the exercise program and benefit from its positive effects on blood pressure and overall health.
Choice B reason: This is the best intervention to help the client maintain the exercise program. Adapting the program to the client's needs and abilities ensures that the exercise is appropriate, safe, and effective for the client. It also increases the client's confidence, satisfaction, and adherence to the program.
Choice C reason: Providing the client with specific details of how to perform the exercises is an important intervention, but not the best one. The client may still have difficulties or barriers to maintaining the exercise program, such as lack of time, resources, or motivation. The nurse should also assess the client's readiness, preferences, and goals for the exercise program.
Choice D reason: Reassuring the client that they will be able to do the exercise program is a supportive intervention, but not the best one. The client may not feel reassured if the exercise program is too challenging, unrealistic, or unappealing for them. The nurse should also monitor the client's progress, feedback, and outcomes of the exercise program.
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