A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?
Weight loss of 1 kg (2.2 lb) in the past 24 hr
Pale, clammy skin
Fatigue when ambulating 152 m (500 ft)
Productive cough with pink, frothy sputum
The Correct Answer is D
A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure.
It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation.
Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Informed consent is a critical step before any invasive procedure, including an EGD. The nurse should confirm that the client has received the necessary information about the procedure, its risks and benefits, and has given their consent voluntarily. This ensures that the client understands the procedure and its implications, making it an essential part of their rights and safety.
Correct Answer is B
Explanation
The guideline of being able to fit one finger between the mattress and the side of the crib ensures that there is a safe space to prevent entrapment and suffocation risks.
Placing a newborn on a pillow for sleep is unsafe. Infants should be placed on their backs to sleep on a firm, flat surface without pillows, blankets, or soft bedding. This reduces the risk of suffocation or sudden infant death syndrome (SIDS).
Attaching a pacifier to the newborn's clothing with a string is hazardous. Strings and cords pose a strangulation risk. Pacifiers should be used according to safe guidelines, but they should not be attached to the baby's clothing with any type of string or cord.
Placing a newborn's crib near a heat vent can result in overheating, which is a safety concern. It is important to keep the baby's sleep environment at a comfortable temperature without direct exposure to heat sources or drafts
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