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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Review the child's electronic pain diary: This should be the first action as it provides valuable information about the frequency, triggers, duration, and severity of the headaches. It helps the nurse and provider make informed decisions about treatment and next steps.
B. Request a change in medication from the provider: Medication changes should be based on a thorough assessment of the child’s headache pattern and response to current therapy, which starts with reviewing documented data.
C. Set up an appointment with the school nurse: While coordination with the school is important for managing chronic conditions, it is not the priority action before understanding the nature and pattern of the headaches.
D. Refer the family to a chronic pain support group: Support groups are helpful in long-term management, but should follow a thorough assessment and diagnosis of the child’s condition and needs.
Correct Answer is B
Explanation
A. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm and the absence of identifiable P waves. It does not present with a consistent PR interval, making this an incorrect match for the findings.
B. First-degree atrioventricular block: This rhythm is defined by a consistently prolonged PR interval greater than 0.20 seconds with every P wave followed by a QRS complex. A PR interval of 0.35 seconds fits this definition, making this the correct answer.
C. Complete heart block: In third-degree or complete heart block, there is no relationship between P waves and QRS complexes—the atria and ventricles beat independently. The PR interval varies and is not constant.
D. Premature atrial complexes: These are early beats originating from the atria, often with a shortened or normal PR interval and an abnormal P wave. A consistently prolonged PR interval is not characteristic of PACs.
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