Which of the following interventions is most appropriate for a nurse to perform prior to administering Lasix to a client with heart failure?
Advise the client to avoid highfiber foods with the medication.
Encourage the client to consume a potassium rich diet.
Assess the client’s respiratory rate and oxygen saturation.
Instruct the client to increase fluid intake to prevent dehydration.
The Correct Answer is C
Choice A reason: Advise the client to avoid highfiber foods with the medication is not an appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix does not interact with highfiber foods or affect the digestion directly. Highfiber foods can actually help prevent or treat constipation, which can be a side effect of Lasix. The nurse should encourage the client to eat a balanced and nutritious diet, unless they have any dietary restrictions or allergies.
Choice B reason: Encourage the client to consume a potassium rich diet is not an appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix can also cause the loss of potassium in the urine, which can lead to hypokalemia, a condition that causes muscle weakness, cramps, arrhythmias, or cardiac arrest. The nurse should monitor the serum potassium level and administer potassium supplements or potassiumsparing diuretics as prescribed to prevent hypokalemia. Consuming a potassium rich diet may not be sufficient or safe to correct the potassium imbalance caused by Lasix, especially in clients with kidney impairment or other medications that affect the potassium level.
Choice C reason: Assess the client’s respiratory rate and oxygen saturation is the most appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix can help reduce the fluid overload and congestion in the lungs, which can cause shortness of breath, difficulty breathing, fatigue, and low oxygen levels in clients with heart failure. The nurse should assess the client’s respiratory rate and oxygen saturation to evaluate the severity of the pulmonary edema and the effectiveness of the Lasix therapy. The nurse should also monitor the client’s vital signs, fluid intake and output, and weight to ensure adequate fluid balance and hemodynamic stability.
Choice D reason: Instruct the client to increase fluid intake to prevent dehydration is not an appropriate intervention for a nurse to perform prior to administering Lasix to a client with heart failure. Lasix is a medication that increases the urine output and lowers the blood pressure by inhibiting the reabsorption of sodium and water in the kidney. Lasix can cause dehydration, which can lead to symptoms such as thirst, dry mouth, dark urine, and fatigue. However, increasing fluid intake to prevent dehydration can worsen the fluid overload and congestion in the lungs, which can cause shortness of breath, difficulty breathing, fatigue, and low oxygen levels in clients with heart failure. The nurse should advise the client to drink enough fluids to maintain hydration, but not to exceed the prescribed fluid restriction, which is usually around 1.52 liters per day. The nurse should also educate the client about the signs and symptoms of dehydration and fluid overload, and when to seek medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Distribution is not the correct term to describe the movement of a drug from its site of administration to the bloodstream. Distribution is the process by which a drug moves from the bloodstream to the tissues and organs of the body. Distribution depends on factors such as blood flow, tissue permeability, plasma protein binding, and tissue binding. Distribution occurs after the drug has been absorbed into the bloodstream, and it determines how much drug reaches the site of action.
Choice B reason: Metabolism is not the correct term to describe the movement of a drug from its site of administration to the bloodstream. Metabolism is the process by which a drug is chemically transformed in the body, usually by enzymes in the liver or other tissues. Metabolism can affect the activity, duration, and elimination of a drug. Metabolism occurs after the drug has been absorbed into the bloodstream, and it can occur before or after the drug reaches the site of action.
Choice C reason: Excretion is not the correct term to describe the movement of a drug from its site of administration to the bloodstream. Excretion is the process by which a drug or its metabolites are eliminated from the body. Excretion can occur through various routes, such as urine, feces, sweat, or breath. Excretion occurs after the drug has been absorbed into the bloodstream, and it can occur before or after the drug reaches the site of action.
Choice D reason: Absorption is the correct term to describe the movement of a drug from its site of administration to the bloodstream. Absorption is the process by which a drug enters the bloodstream from the site of administration. Absorption depends on factors such as the route of administration, the dose, the formulation, and the bioavailability of the drug. Absorption is the first step of pharmacokinetics, and it determines how much and how fast a drug reaches the bloodstream and the site of action.
Correct Answer is D
Explanation
Choice A reason: Monoamine oxidase inhibitors (MAOIs) are not the correct class of medications to which escitalopram (Lexapro) belongs. MAOIs are a group of antidepressants that work by inhibiting the enzyme monoamine oxidase, which breaks down neurotransmitters such as serotonin, norepinephrine, and dopamine. MAOIs can increase the levels of these neurotransmitters in the brain and improve mood and energy. However, MAOIs can also cause serious side effects and interactions with other drugs and foods, and they are not commonly used as firstline treatment for depression. Escitalopram is not an MAOI, and it should not be taken with MAOIs or within 14 days of stopping or starting MAOIs, as this can cause a dangerous drug interaction called serotonin syndrome.
Choice B reason: Betablockers are not the correct class of medications to which escitalopram (Lexapro) belongs. Betablockers are a group of drugs that work by blocking the beta receptors on the heart and blood vessels, which are stimulated by adrenaline and noradrenaline. Betablockers can lower the heart rate, blood pressure, and cardiac output, and they are used to treat conditions such as hypertension, angina, arrhythmias, and heart failure. Betablockers can also reduce anxiety and tremors, but they are not antidepressants and they do not affect serotonin levels. Escitalopram is not a betablocker, and it does not have any significant effect on the cardiovascular system.
Choice C reason: Benzodiazepines are not the correct class of medications to which escitalopram (Lexapro) belongs. Benzodiazepines are a group of drugs that work by enhancing the activity of the neurotransmitter gammaaminobutyric acid (GABA), which has a calming and sedating effect on the brain. Benzodiazepines are used to treat anxiety, insomnia, seizures, and muscle spasms, and they can also cause relaxation, drowsiness, and amnesia. Benzodiazepines are not antidepressants and they do not affect serotonin levels. Escitalopram is not a benzodiazepine, and it does not have any significant effect on GABA receptors .
Choice D reason: Selective serotonin reuptake inhibitors (SSRIs) are the correct class of medications to which escitalopram (Lexapro) belongs. SSRIs are a group of antidepressants that work by blocking the reuptake of serotonin by the nerve cells, which increases the availability of serotonin in the synaptic cleft. Serotonin is a neurotransmitter that regulates mood, appetite, sleep, and cognition, and low levels of serotonin are associated with depression and anxiety. SSRIs can improve the symptoms of depression and anxiety by enhancing the serotonin signaling in the brain. Escitalopram is an SSRI, and it is used to treat major depressive disorder and generalized anxiety disorder.
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