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 C
Explanation
A. Avoid eating seafood to minimize risk to the newborn: Seafood contains important nutrients like omega-3 fatty acids that support infant brain development; moderate consumption of low-mercury seafood is generally safe and encouraged during breastfeeding.
B. Wait 1 hour to breastfeed after consuming alcohol: Alcohol peaks in breast milk approximately 30 to 60 minutes after consumption; waiting only 1 hour may not be sufficient to prevent infant exposure depending on the amount consumed.
C. Consume additional calories each day to support milk production: Breastfeeding increases a mother’s energy needs by about 450 to 500 calories per day, so additional caloric intake is necessary to maintain adequate milk supply and support maternal health.
D. Caffeine slowly enters breast milk after maternal consumption: Caffeine passes into breast milk relatively quickly, usually within 30 to 60 minutes after ingestion, so it does not enter slowly but rather fairly rapidly after consumption.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.