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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.

B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.

C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.

D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.

A. "Your body temperature will drop approximately 1 degree 1 week after ovulation." B. "You should take your body temperature each evening prior to going to sleep." C. "Your body temperature might decrease slightly just prior to ovulation." D. "Your body temperature is at its highest during menstruation."

Correct Answer is C

Explanation

A. This choice is incorrect because the body temperature does not drop 1 degree 1 week after ovulation. The body temperature rises slightly (about 0.4 to 0.8 degrees Fahrenheit) after ovulation and remains elevated until the next menstrual period.

B. This choice is incorrect because the body temperature should be taken each morning before getting out of bed or doing any activity. Taking the temperature in the evening can result in inaccurate readings due to variations in daily activities, meals, stress, exercise, etc.

C. This choice is correct because the body temperature might decrease slightly (about 0.2 degrees Fahrenheit) just prior to ovulation due to a surge in estrogen levels. This dip in temperature can indicate that ovulation is about to occur and that the client should avoid unprotected intercourse if she wants to prevent pregnancy.

D. This choice is incorrect because the body temperature is not at its highest during menstruation. The body temperature drops at the onset of menstruation due to a decline in progesterone levels and marks the beginning of a new cycle.

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A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

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