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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?

A.

Insert an indwelling urinary catheter.

B.

Administer an IV diuretic.

C.

Initiate oxygen via face mask.

D.

Request an analysis of ABGs.

Answer and Explanation

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.
 


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

  • Minimize environmental stimuli for the client: This is appropriate because clients experiencing acute mania are highly distractible and overstimulated. A low-stimulation environment helps reduce agitation and promotes safety.
  • Weigh the client each day: Daily weights are necessary as manic clients often exhibit decreased nutritional intake and increased physical activity, placing them at risk for weight loss and dehydration.
  • Provide the client with high-calorie fluids every hour: Frequent intake of calorie-dense fluids supports the client’s nutritional needs without requiring prolonged focus or interruption of hyperactive behavior.
  • Encourage the client to avoid napping during the day: This is contraindicated because rest is crucial during manic episodes. Encouraging naps supports mood stabilization and prevents exacerbation of manic symptoms due to sleep deprivation.

Correct Answer is B

Explanation

A. "Season foods with salt and pepper.": Spicy and seasoned foods can irritate the gastric mucosa, potentially worsening gastritis symptoms, so this advice is not appropriate.
B. "Eat small frequent meals daily.": Smaller, more frequent meals help reduce gastric acid secretion and minimize irritation of the stomach lining, which can alleviate symptoms of gastritis and promote healing.
C. "Use ibuprofen as needed for discomfort.": Nonsteroidal anti-inflammatory drugs like ibuprofen can exacerbate gastritis by irritating the stomach lining and increasing the risk of bleeding, so they should be avoided.
D. "Take a Vitamin E supplement daily.": There is no clear evidence supporting the use of vitamin E supplements for gastritis management, and supplementation is not a standard recommendation in this condition.

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