Difficulty: Medium
Average Score: 90%
Simulated
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?
Correct answer
A
Rationale
The correct answer is A: Withhold the dose and reassess the blood pressure in 30 minutes. The client's low blood pressure (90/60) indicates hypotension, which can be exacerbated by the administration of furosemide, a diuretic that can further decrease blood pressure. Withholding the dose allows the nurse to monitor the client's blood pressure closely and reassess for signs of hypotension before administering the medication. This cautious approach prioritizes the safety of the client by preventing potential complications from administering the medication when the blood pressure is already low.
Choice B is incorrect because administering the medication without addressing the low blood pressure could worsen the client's condition. Choice C is incorrect as it does not address the existing low blood pressure. Choice D is incorrect as oral furosemide may not be appropriate for a client with acute pulmonary congestion and fluid overload.
Choice B is incorrect because administering the medication without addressing the low blood pressure could worsen the client's condition. Choice C is incorrect as it does not address the existing low blood pressure. Choice D is incorrect as oral furosemide may not be appropriate for a client with acute pulmonary congestion and fluid overload.