A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Pink, frothy sputum
Bradycardia
Flushed, dry skin
Wheezing
The Correct Answer is A
A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.
B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.
C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.
D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.
B. Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.
C. Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.
D. Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.
Correct Answer is B
Explanation
- Urinary output is an important indicator of fluid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess fluid that was retained during pregnancy and the diuretic effect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
- However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
- Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.
Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.
Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.
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