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. “I wear a hat and long sleeves while I am working.”: This suggests protective behavior that reduces the risk of sun exposure, heat-related illnesses, and contact with harmful agricultural chemicals, indicating awareness of occupational safety.
B. “I am currently sharing my home with two roommates.”: Although crowded living conditions can increase transmission risk of communicable diseases, this alone is not immediately indicative of a health hazard without other factors like poor sanitation.
C. “I eat vegetables directly from the field where I work.”: Consuming unwashed produce in the field exposes individuals to pesticide residues, soil contaminants, and pathogens, posing a significant health risk that requires immediate education and intervention.
D. “My home has running water and electricity.”: Access to clean water and electricity supports good hygiene and safe food preparation, which are positive indicators of living conditions that help reduce health risks.
Correct Answer is B
Explanation
A. Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. It is not effective in treating allergic reactions like urticaria caused by antibiotics.
B. Diphenhydramine: Diphenhydramine is an antihistamine used to treat allergic reactions, including urticaria. It blocks histamine release, reducing itching, redness, and swelling associated with allergic responses.
C. Hydralazine: Hydralazine is an antihypertensive medication used to treat severe high blood pressure. It has no role in managing allergic reactions and would not address the urticaria symptoms.
D. Protamine: Protamine is used to reverse the effects of heparin in cases of overdose or bleeding. It does not counteract allergic responses and is not indicated for urticaria.
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