A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning.
The nurse should recognize these assessment findings as indicating which of the following?
Increased cardiac output.
Pleural effusion.
Fluid volume excess.
Aspiration.
The Correct Answer is C
“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess.
Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates an understanding of the teaching because cool, clammy skin is a common symptom of hypoglycemia.
Choice B is incorrect because acetone breath is a symptom of hyperglycemia (high blood sugar), not hypoglycemia (low blood sugar).
Choice C is incorrect because Kussmaul respirations (deep and labored breathing) are a symptom of hyperglycemia, not hypoglycemia.
Choice D is incorrect because increased urine output is a symptom of hyperglycemia, not hypoglycemia.
Correct Answer is B
Explanation
The priority action for a nurse caring for an older adult client who is suspected of having septicemia is to obtain a blood specimen for culture and sensitivity testing.
This test will help identify the specific microorganism causing the infection and determine the most effective antibiotic treatment.
Choice A is incorrect because while a WBC count with differential can provide information about the presence of an infection, it does not identify the specific microorganism causing the infection.
Choice C is incorrect because while obtaining a history to determine recent injuries can provide useful information, it is not the priority action.
Choice D is incorrect because while administering a broad-spectrum antibiotic may be necessary, it should not be done before obtaining a blood specimen for culture and sensitivity testing.
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