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 second intercostal space, right of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, right of sternum, is the location where the aortic valve can be best heard, but not the location where the aortic murmur will be most audible. ³
Choice B reason: The third intercostal space, left of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The third intercostal space, left of sternum, is the location where the pulmonary valve, which separates the right ventricle and the pulmonary artery, can be best heard, but not the location where the aortic murmur will be most audible. ³
Choice C reason: The second intercostal space, left of sternum, is the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, left of sternum, is the location where the aortic murmur will be most audible, as it is the closest to the aorta, the largest artery in the body. ³
Choice D reason: The fourth intercostal space, left mid-clavicular line, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The fourth intercostal space, left mid-clavicular line, is the location where the tricuspid valve, which separates the right atrium and the right ventricle, can be best heard, but not the location where the aortic murmur will be most audible. ³
Correct Answer is B
Explanation
Choice A reason: This is incorrect. Walking directly in front of the client may block their view and increase their risk of falling. The nurse should walk to the side and slightly behind the client to provide support and guidance³.
Choice B reason: This is correct. Walking along the affected left side allows the nurse to assist the client with balance, weight shifting, and foot clearance. The nurse should also encourage the client to use the handrail on their strong side³.
Choice C reason: This is incorrect. Walking directly behind the client may not allow the nurse to see the client's gait pattern or intervene quickly if the client loses balance. The nurse should walk to the side and slightly behind the client to monitor and assist them³.
Choice D reason: This is incorrect. Walking along the unaffected right side may not provide adequate support or protection for the client's affected side. The nurse should walk along the affected left side to help the client with their hemiplegic gait³.
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