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 C
Explanation
A. A client who consumes all the food from their meal tray: Eating a full meal is generally positive and does not require immediate reporting unless related to specific dietary restrictions or concerns.
B. A client who requests assistance to use the bedside commode: Requesting help to use the commode is expected and can be managed by the assistive personnel without urgent nurse notification.
C. A client who has a prescription for compression stockings and did not receive them: Compression stockings prevent deep vein thrombosis and promote circulation. Not receiving them as prescribed is a safety concern that requires prompt nurse awareness and intervention.
D. A client who requests to sit in the bedside chair while watching TV: This is a normal, non-urgent request that the assistive personnel can usually handle without needing to notify the nurse immediately.
Correct Answer is A
Explanation
A. Prime the tubing with 0.9% sodium chloride: Normal saline is the only compatible solution used to prime blood transfusion tubing. It prevents clotting or hemolysis and ensures that blood components are not damaged during administration.
B. Attach a single-line administration set: A Y-type or dual-line administration set with a filter is required for safe transfusion. Single-line sets do not allow simultaneous saline flushing, which is necessary during transfusion to prevent clotting and maintain patency.
C. Use an IV catheter that is at least 24 gauge: While a 24-gauge catheter can be used in pediatric clients, adults require at least an 18–20 gauge catheter to prevent hemolysis and ensure rapid infusion of blood products when needed.
D. Use tubing that does not have a filter in the drip chamber: Blood administration sets must include a filter to trap clots and debris. Using tubing without a filter increases the risk of transfusion-related complications such as embolism or febrile reactions.
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