Difficulty: Medium
Average Score: 90%
Simulated
The nurse is admitting a 69-year-old male patient with acute heart failure. The physician has ordered furosemide 80 mg IV stat, digoxin 0.25 mg PO, and potassium chloride 20 mEq PO now. Which assessment finding is most indicative of an ineffective response 2 hours after the administration of all the medications?
Correct answer
D
Rationale
A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.