A nurse is caring for a client who has acute pulmonary edema. Which of the following is the priority nursing intervention?
Insert an indwelling urinary catheter.
Administer an IV diuretic.
Initiate oxygen via face mask.
Request an analysis of ABGs.
The Correct Answer is C
A. Insert an indwelling urinary catheter: This may be necessary to monitor fluid output after diuretic therapy, but it is not the immediate priority when oxygenation is compromised due to fluid in the lungs.
B. Administer an IV diuretic: Diuretics help reduce fluid overload, which is key in managing pulmonary edema, but oxygenation must be addressed first to stabilize the client and prevent hypoxia.
C. Initiate oxygen via face mask: The most urgent concern in acute pulmonary edema is impaired gas exchange. Administering oxygen immediately helps improve oxygenation and is the priority intervention to address life-threatening hypoxia.
D. Request an analysis of ABGs: While ABG results are important to assess respiratory function and guide further treatment, drawing labs takes time. Oxygen administration should not be delayed in order to obtain lab values.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client if they would prefer a translator who is the same gender: Cultural sensitivity includes acknowledging gender preferences in healthcare interactions. Offering a choice respects the client’s values and supports effective, respectful communication.
B. Ask a nursing student who speaks the same language as the client to translate: Using untrained staff or students as interpreters can lead to errors or breaches in confidentiality. Only qualified medical interpreters should be used to ensure accuracy and professionalism.
C. Use a website with a ".com" URL to translate for the client: Online translation tools are not reliable for medical communication. They can lead to serious misunderstandings and are not appropriate for clinical use.
D. Request a family member of the client to translate: Family members may lack the language skills or medical knowledge to translate accurately and may filter or misinterpret information. This can compromise informed consent and patient safety.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
- Prepare the client for cardiac catheterization: This client is experiencing an ST-elevation myocardial infarction (STEMI), a medical emergency requiring reperfusion therapy. Preparing for cardiac catheterization aligns with standard emergency management to restore coronary blood flow.
- Administer morphine 2 mg IV bolus for persistent cardiac pain: Morphine is used to relieve chest pain unresponsive to nitrates and reduce myocardial oxygen demand by lowering preload and afterload. The client still reports severe pain (7/10), justifying its use.
- Administer aspirin 81 mg PO chewable tablet: Aspirin is a first-line treatment in acute coronary syndromes to inhibit platelet aggregation and limit thrombus formation. A chewable form provides quicker absorption and is routine for suspected MI.
- Prepare to intubate the client: The client is alert, oriented, has normal respiratory rates, and maintains adequate oxygen saturation (96–98% on room air). There is no evidence of respiratory failure or airway compromise to justify intubation.
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