The prescriber orders furosemide 80 mg for a patient who has been retaining extra fluid after surgery. The nurse notes the following: BP of 142/88 (lying) and 108/60 (sitting); daily weight of 154 lb, a 1-lb drop from day before; serum potassium of 2.8 mEq/L.
What should the nurse do?
Administer medication.
Contact provider.
Hold medication
Give potassium supplement
The Correct Answer is B
The nurse should contact the provider before administering furosemide because the patient has a low serum potassium level of 2.8 mEq/L, which is below the normal range of 3.5 to 5.0 mEq/L. Furosemide is a diuretic that can cause potassium loss and worsen hypokalemia, which can lead to cardiac arrhythmias, muscle weakness, and fatigue. The nurse should also monitor the patient’s blood pressure, weight, and urine output, as furosemide can lower blood pressure and cause dehydration.
Choice A. Administer medication is wrong because the nurse should not give furosemide without checking with the provider first, as it could be harmful to the patient with low potassium.
Choice C. Hold medication is wrong because the nurse should not withhold furosemide without a valid reason or an order from the provider, as it could cause fluid overload and worsen the patient’s condition.
Choice D. Give potassium supplement is wrong because the nurse should not give potassium supplement without an order from the provider, as it could cause hyperkalemia or interact with other medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nitroglycerin sublingual is a medication that is used to treat chest pain or angina by relaxing the blood vessels and reducing the oxygen demand of the heart.A common side effect of nitroglycerin sublingual is headache, which may be severe and throbbing.Headache is often a sign that the medication is working.Other possible side effects include flushing, dizziness, lightheadedness, nausea, vomiting, fast heart rate, numbness, tingling, burning pain, rash, hives, sweating, pale skin, difficulty breathing and allergic reaction.
Choice A is wrong because nausea is not the most common adverse effect of nitroglycerin sublingual.Nausea may occur in some people, but it is usually mild and transient.
Choice B is wrong because bradycardia (slow heart rate) is not a common adverse effect of nitroglycerin sublingual.Nitroglycerin sublingual may cause tachycardia (fast heart rate) in some people as a result of vasodilation and reflex stimulation of the heart.
Choice C is wrong because hypertension (high blood pressure) is not a common adverse effect of nitroglycerin sublingual.Nitroglycerin sublingual may cause hypotension (low blood pressure) in some people due to its vasodilating action.Hypotension may lead to lightheadedness, fainting or shock in severe cases.
The normal range for blood pressure is less than 120/80 mmHg for adults.
The normal range for heart rate is 60 to 100 beats per minute for adults.
Correct Answer is C
Explanation
Anticoagulants are medicines that increase the time it takes for blood to clot.They do not dissolve existing clots, but they can stop them from getting bigger or prevent new clots from forming.Anticoagulants work by interfering with different steps of the blood coagulation pathway, which is a complex process that involves many clotting factors.
Choice A is wrong because anticoagulants do not dissolve existing clots.To dissolve clots, you need medicines called thrombolytics or fibrinolytics, which break down the fibrin that holds the clots together.
Choice B is wrong because anticoagulants do not transport platelets.
Platelets are blood cells that help with clotting by sticking together and forming a plug at the site of an injury.Anticoagulants may affect the function of platelets, but they do not move them around.
Choice D is wrong because anticoagulants do not increase blood viscosity.
Viscosity is a measure of how thick and sticky a fluid is.
Anticoagulants are sometimes called blood thinners, but they do not actually change the viscosity of blood.They just make it less likely to clot.
Normal ranges for blood clotting tests vary depending on the type of test and the laboratory that performs it.
Some common tests and their normal ranges are:
• Prothrombin time (PT): 11 to 13.5 seconds
• International normalized ratio (INR): 0.8 to 1.2
• Activated partial thromboplastin time (aPTT): 25 to 35 seconds
• Anti-factor Xa: 0.3 to 0.7 units/mL
• D-dimer: less than 0.5 mcg/mL
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