The physician has ordered hydrochlorothiazide (HCTZ) for the patient in chronic renal failure. The nurse suspects the patient is experiencing an ineffective response to the medication. Which assessment is a priority for this patient?
1. Reviewing the lab work for hypokalemia and hyponatremia
2. Assessing the vital signs for hypertension
3. Assessing the skin for moisture and turgor
4. Auscultating breath sounds for wheezes
4
Rationale 1: Reviewing lab work is important but is not the priority here.
Rationale 2: Vital sign assessment is important but is not the priority here.
Rationale 3: Skin assessment is important but is not the priority here.
Rationale 4: Wheezes are commonly auscultated with pulmonary edema, which can occur with chronic renal failure and fluid retention. This is a priority because pulmonary edema affects the patient's oxygenation.
Global Rationale: Wheezes are commonly auscultated with pulmonary edema, which can occur with chronic renal failure and fluid retention. This is a priority because pulmonary edema affects the patient's oxygenation. Skin assessment is important but is not the priority here. Vital sign assessment is important but is not the priority here. Reviewing lab work is important but is not the priority here.
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