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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Instruct the client to wash her hands before and after changing her perineal pad: Good perineal hygiene is essential in preventing the spread or worsening of infection, especially when endometritis is suspected.
B. Initiate contact precautions: Contact precautions are not necessary for endometritis, which is not a contagious condition. Standard precautions are sufficient.
C. Monitor the height and tone of the client's fundus: Fundal assessment is important to detect uterine atony and evaluate the response to methylergonovine, which is prescribed to improve uterine tone and reduce postpartum bleeding.
D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: This position promotes lochial drainage and prevents pooling of infected discharge in the uterine cavity, supporting infection resolution.
E. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used for postpartum infections, including clindamycin, are compatible with breastfeeding. Breastfeeding is usually encouraged unless contraindicated.
F. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to relax the uterus in preterm labor, not to treat postpartum infection or improve uterine tone. Methylergonovine is already prescribed for uterine tone enhancement.
G. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Cultures from a perineal pad may be contaminated. If needed, endometrial cultures are obtained using a sterile technique via the cervix.

A. Methylergonovine B. Carboprost C. Nifedipine D. Oxytocin

Correct Answer is D

Explanation

A. Methylergonovine: While effective for postpartum hemorrhage, it causes vasoconstriction and can raise blood pressure significantly. It is contraindicated in clients with preeclampsia or hypertension due to the risk of stroke or hypertensive crisis.
B. Carboprost: Carboprost is used to treat postpartum hemorrhage, but it may increase blood pressure and is used cautiously in clients with preeclampsia. It is not typically the first-line treatment in hypertensive patients.
C. Nifedipine: Nifedipine is a calcium channel blocker used for managing hypertension and preterm labor, not for controlling postpartum bleeding. It does not cause uterine contraction and is not effective for hemorrhage.
D. Oxytocin: Oxytocin stimulates uterine contractions and is the first-line medication for managing postpartum hemorrhage. It does not raise blood pressure, making it safe and effective for clients with preeclampsia.

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A nurse is caring for a client who has acute pulmonary edema. Which of the following is the priority nursing intervention?

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Naxlex Comprehensive Predictor Exams

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Explanation

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