A nurse is caring for a client who has acute pulmonary edema. Which of the following is the priority nursing intervention?

Administer an IV diuretic

Request an analysis of ABGs

Initiate oxygen via face mask

Insert an indwelling urinary catheter

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering an IV diuretic is important to reduce fluid overload, but it is not the immediate priority. Diuretics take time to act, and the client’s oxygenation must be stabilized first.

Choice B reason: Requesting an analysis of ABGs provides valuable diagnostic information, but it is not the priority intervention. ABG analysis does not directly improve oxygenation or relieve symptoms in the acute phase.

Choice C reason: Initiating oxygen via face mask is the priority because pulmonary edema impairs gas exchange, leading to hypoxemia. Immediate oxygen administration improves oxygen saturation and prevents tissue hypoxia while other interventions are prepared.

Choice D reason: Inserting an indwelling urinary catheter may be necessary for monitoring urine output when diuretics are administered, but it is not urgent compared to restoring oxygenation.

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Correct Answer is A

Explanation

Choice A reason: A flat anterior fontanel indicates adequate hydration. In dehydration, the fontanel becomes sunken, so normalization shows effective treatment.

Choice B reason: Skin turgor displaying tenting is a sign of persistent dehydration, not improvement.

Choice C reason: Hyperpnea (rapid breathing) suggests metabolic acidosis or ongoing fluid imbalance, not resolution.

Choice D reason: Cool, mottled skin indicates poor perfusion and continued dehydration, not effective treatment.

A. The client will reach an appropriate body weight. B. The client will gain 2 to 3 lb weekly. C. The client will verbalize a realistic body image. D. The client will develop a personalized meal plan.

Correct Answer is B

Explanation

Choice A reason: Reaching an appropriate body weight is a long-term goal, not a short-term one. Clients with anorexia nervosa require gradual weight restoration to avoid complications such as refeeding syndrome. Setting this as a short-term goal is unrealistic and potentially unsafe.

Choice B reason: Gaining 2 to 3 lb weekly is the correct short-term goal because it is measurable, realistic, and safe. This gradual increase helps stabilize the client’s nutritional status while minimizing medical risks. It also provides a tangible benchmark for progress during inpatient treatment.

Choice C reason: Verbalizing a realistic body image is important but represents a long-term psychosocial goal. Distorted body image is a core feature of anorexia nervosa and requires extended therapy and counseling. It cannot be expected as a short-term outcome during initial hospitalization.

Choice D reason: Developing a personalized meal plan is a collaborative long-term strategy involving dietitians and therapists. While important, it is not the immediate short-term focus. The priority is safe, gradual weight gain.

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A nurse is caring for a client who has acute pulmonary edema. Which of the following is the priority nursing intervention?

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