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The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention?

a. Insert an indwelling urinary catheter.
b. Monitor the client's blood pressure.
c. Place the nitroglycerin under the client's tongue.
d. Monitor the client's serum glucose level.

1 Answer

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Final answer:

The priority nursing intervention is to monitor the client's blood pressure due to the risk of hypotension from the intravenous nitroglycerin and the diuretic effects of furosemide (Lasix).

Step-by-step explanation:

The priority nursing intervention for a client with heart failure who has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema is b. Monitor the client's blood pressure. Nitroglycerin is used to improve blood flow by dilating blood vessels, which can lead to a drop in blood pressure. Furosemide (Lasix) is a powerful diuretic that works on the loop of Henle, inhibiting the reabsorption of Na+ and Cl-, helping to reduce fluid volume and pulmonary edema. Due to the potential for hypotension, it is critical to monitor the client's blood pressure to ensure stability and prevent complications such as shock. Placing nitroglycerin under the client's tongue would not apply in this case, because the medication is being given intravenously. Inserting an indwelling urinary catheter may be necessary for management but is not the immediate priority. Monitoring the client's serum glucose is also important, but not the primary concern in the acute management of pulmonary edema.

User Bob Kusik
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