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. “Use an indoor tanning bed instead of outside.”: Indoor tanning exposes the skin to concentrated ultraviolet radiation, which significantly increases the risk of developing skin cancer, including melanoma. It is not a safe alternative to outdoor sun exposure.
B. “Plan to spend time tanning between 10 am and 2 pm.”: This time frame represents peak UV radiation hours, and sun exposure should be minimized during this period to reduce the risk of skin damage and cancer.
C. “Apply sunscreen before and after swimming.”: Sunscreen should be applied 15–30 minutes before sun exposure and reapplied after swimming or sweating. Water can wash off sunblock, so reapplication helps maintain effective protection against UV rays.
D. “Use sunblock with an SPF of 10 when I am outdoors.”: An SPF of 10 provides minimal protection and is inadequate for preventing skin damage. A minimum SPF of 30 is recommended for effective protection against both UVA and UVB radiation.
Correct Answer is ["C","D","E"]
Explanation
A. Inform the client that they cannot refuse medical examination: All patients, including those who have been sexually assaulted, have the legal right to refuse any part of the examination. Informed consent is essential.
B. Report laboratory findings to law enforcement: Unless there is a mandatory reporting law in effect for that specific jurisdiction, results and disclosures require the client's consent before being shared with law enforcement.
C. Prepare to administer prophylaxis for STIs: Clients who have experienced sexual assault are at risk for sexually transmitted infections. Early administration of prophylactic antibiotics is a standard, time-sensitive intervention.
D. Assess for thoughts of self-harm: Sexual assault survivors are at increased risk for depression, suicidal ideation, and PTSD. A mental health assessment should be conducted immediately to ensure safety.
E. Recommend emergency contraception to the client: If pregnancy is a potential concern, emergency contraception should be offered within a limited time window after the assault, regardless of the client’s current hCG level.
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