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 B
Explanation
A. Fibrinogen level: This test measures a clotting factor important for hemostasis, but it is not routinely used to monitor warfarin therapy. Fibrinogen levels are more relevant in evaluating bleeding disorders or liver function.
B. INR: The International Normalized Ratio is the standard test used to monitor warfarin effectiveness. It helps determine the appropriate dosing needed to maintain therapeutic anticoagulation and reduce the risk of bleeding or thromboembolism.
C. APTT: Activated partial thromboplastin time is used to monitor heparin therapy, not warfarin. It evaluates the intrinsic pathway of coagulation and is not a reliable indicator of warfarin activity.
D. Platelet count: While important in assessing bleeding risk, platelet count does not provide information on the anticoagulant effect of warfarin. It is not used to guide warfarin dosing decisions.
Correct Answer is ["A","B","C","D"]
Explanation
A. Hallucinations: The client appears to be responding to unseen stimuli, indicating auditory hallucinations. This psychotic feature requires immediate follow-up due to risks of harm to self or others.
B. Hygiene: Although the client is unclean, poor hygiene is a common and non-urgent symptom during manic episodes. It does not require immediate intervention compared to issues with psychosis, dehydration, or cardiovascular stability.
C. Heart rate: The client’s heart rate is 120/min, which is tachycardia (normal range: 60–100/min). This may reflect dehydration, overstimulation, or a manic state and requires urgent assessment.
D. Skin turgor: Poor skin turgor suggests dehydration, possibly from inadequate intake during mania. Dehydration can worsen cognitive status and vital signs and must be addressed quickly.
E. Sleep pattern: The client has not slept in 2 days, which is dangerous in manic states. Severe sleep deprivation increases the risk for psychosis, agitation, and physical exhaustion, requiring prompt intervention.
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