An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client’s response to treatment? (Select all that apply.)
A.
Skin elasticity.
B.
Urinary output.
C.
Oxygen saturation.
D.
Lung sounds.
E.
Pain scale.
The correct answer and Explanation is :
The correct assessments to determine the client’s response to furosemide treatment are:
B. Urinary output.
C. Oxygen saturation.
D. Lung sounds.
Explanation:
The client is presenting with signs of respiratory distress, dyspnea, and cardiovascular instability, potentially indicating heart failure or fluid overload. Furosemide, a loop diuretic, works by promoting diuresis, helping to reduce fluid overload and ease the workload on the heart and lungs. To evaluate the effectiveness of this intervention, certain key assessments are critical:
- B. Urinary Output: Furosemide increases urine production by inhibiting sodium and chloride reabsorption in the kidneys. Monitoring urinary output is essential to determine if the medication is effective in reducing excess fluid. A significant increase in urine output suggests a positive response to treatment.
- C. Oxygen Saturation: Since the client has respiratory distress, monitoring oxygen saturation is important to assess improvement in respiratory function. If furosemide successfully reduces pulmonary congestion and fluid in the lungs, oxygen saturation should improve.
- D. Lung Sounds: Assessing lung sounds is crucial because furosemide is intended to relieve pulmonary congestion. Initially, the client had wheezes and crackles in all lung fields, indicating fluid accumulation in the lungs. Improved lung sounds—fewer or no crackles and wheezes—would indicate that the fluid has been reduced.
Incorrect Options:
- A. Skin Elasticity: This assessment is more relevant for evaluating hydration status, particularly in cases of dehydration. In this scenario, it is less critical for assessing the response to furosemide treatment in a client with fluid overload.
- E. Pain Scale: While pain assessment is important in general, it is not directly relevant to determining the effectiveness of diuretic therapy in this case.
By focusing on urinary output, oxygen saturation, and lung sounds, the nurse can evaluate the client’s physiological response to diuresis and determine if the treatment is alleviating the symptoms of fluid overload.