A nurse is caring for a client with pulmonary edema. Which finding is indicative of severe pulmonary edema and impaired gas exchange?
Pink, frothy sputum
Low-grade fever
Clear breath sounds throughout the lung fields
Absence of peripheral edema
The Correct Answer is A
A) Correct. Pink, frothy sputum, often described as "pink froth," is indicative of severe pulmonary edema with the presence of blood-tinged fluid in the alveoli.
B) Incorrect. A low-grade fever is not a typical sign of pulmonary edema and may indicate another underlying condition.
C) Incorrect. Clear breath sounds throughout the lung fields are not indicative of severe pulmonary edema, which often presents with crackles.
D) Incorrect. The absence of peripheral edema does not necessarily reflect the severity of pulmonary edema; it may be related to factors other than heart failure.
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Correct Answer is D
Explanation
A) Incorrect. Limiting fluid intake should be based on the client's specific medical recommendations and should not be a general guideline.
B) Incorrect. Avoiding all physical activity is not necessary and can lead to deconditioning. Clients should engage in appropriate physical activity as advised by their healthcare provider.
C) Incorrect. Blood pressure should be regularly monitored as directed by the healthcare provider, not only when symptoms worsen.
D) Correct. Taking prescribed medications as directed, especially diuretics and medications to manage underlying conditions, is crucial in preventing recurrence of pulmonary edema.
Correct Answer is C
Explanation
A) Incorrect. Hyperventilation leading to respiratory alkalosis may occur in response to respiratory distress but is not the primary cause of the sensation of "suffocation."
B) Incorrect. Reduced cardiac output may be a consequence of pulmonary edema, but it does not typically result in bradycardia, nor is it the primary cause of the sensation described.
C) Correct. In pulmonary edema, fluid accumulation in the alveoli impairs oxygen diffusion, leading to hypoxemia, which contributes to the sensation of "suffocation."
D) Incorrect. Elevated blood pressure and hypertension can be associated with heart failure but are not the primary factors contributing to the sensation of "suffocation" in pulmonary edema.
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