NCLEX Exam Practice Question of the Week - 6/13/12

Question:A client with heart failure was experiencing difficulty breathing and increased pulmonary congestion. The physician prescribed furosemide (Lasix) 40 mg to be given intravenously and it was given an hour ago by the nurse. Which indicates the therapy has been effective?

1. The lungs are now clear to auscultation
2. The urine output has increased by 400 mL
3. The serum potassium has decreased from 4.7 mEq to 4.1 mEq
4. The blood pressure has decreased from 118/64 mm Hg to 106/62 mm Hg

Answer: 1

Rationale: Furosemide (Lasix) is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason the furosemide was administered.
Priority Nursing Tip: When administering a medication, knowing its purpose will assist in evaluating its effectiveness.

Test-Taking Strategy: Knowledge of the use of furosemide in heart failure and its side effects is essential. Note the relationship between the words “pulmonary congestion” in the question and option 1. Review the heart failure and the associated medication therapy if you had difficulty with
this question.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Cardiovascular
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 772). Philadelphia: Saunders.

This week’s NCLEX exam practice question came from:

Silvestri: Saunders Q&A Review  for the NCLEX-RN Examination, 5th Edition, Test 1, Page 127, Question 215

Check out other great NCLEX exam review resources from Elsevier!