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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Related Questions
Correct Answer is D
Explanation
A) Incorrect. Regular exercise is generally beneficial for heart health and would not increase the risk of pulmonary edema.
B) Incorrect. Smoking cessation is a positive health behavior and does not increase the risk of pulmonary edema.
C) Incorrect. Hypertension control is important for reducing the risk of heart-related complications and pulmonary edema.
D) Correct. Prior heart muscle damage, such as from a myocardial infarction (MI), increases the risk of heart failure and subsequently pulmonary edema.
Correct Answer is B
Explanation
A) Incorrect. Urinary output is important but does not directly assess the client's oxygenation status.
B) Correct. Monitoring the respiratory rate and effort is essential to ensure the client is adequately oxygenated and not in respiratory distress.
C) Incorrect. Skin turgor is unrelated to oxygenation and pulmonary edema.
D) Incorrect. Bowel sounds do not provide information about the client's oxygenation status.
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