A nurse on a telemetry unit is assisting with the plan of care for a client who has pulmonary edema. Which of the following instructions should the nurse include in the plan of care?

Place the client in a supine position.

Weigh the client every other day.

Encourage the client to ambulate three times per day.

Report urine output less than 30 mL/hr.

Answer and Explanation

The Correct Answer is D

A) Place the client in a supine position:

Placing a client with pulmonary edema in a supine position can exacerbate symptoms by increasing venous return and worsening fluid accumulation in the lungs. Instead, positioning the client upright or in a semi-Fowler's position is more appropriate to facilitate respiratory mechanics and decrease venous return.

B) Weigh the client every other day:

Daily weight monitoring is crucial for clients with pulmonary edema to assess fluid balance accurately. Weighing the client every other day may not provide timely information on fluid retention and response to treatment. Therefore, daily weight measurement is typically recommended.

C) Encourage the client to ambulate three times per day:

While mobility is essential for overall health, clients with pulmonary edema may experience dyspnea and fatigue, limiting their ability to ambulate. Ambulation should be encouraged but should be tailored to the client's tolerance level and may need to be adjusted based on their respiratory status.

D) Report urine output less than 30 mL/hr:

Monitoring urine output is vital in clients with pulmonary edema to assess kidney perfusion and fluid balance. A urine output of less than 30 mL/hr may indicate decreased renal perfusion and impaired fluid clearance, which can exacerbate pulmonary congestion. Therefore, it is crucial to report such findings promptly for further evaluation and intervention.

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Correct Answer is D

Explanation

A) Determine possible alternatives:

After identifying the ethical problem, determining possible alternatives comes later in the ethical reasoning process. This step involves brainstorming potential courses of action or solutions to address the ethical dilemma.

B) Examine the outcomes:

Examining the outcomes occurs after identifying possible alternatives. In this step, the nurse evaluates the potential consequences or outcomes of each alternative to determine which course of action aligns best with ethical principles and achieves the desired goals.

C) Develop a plan of action:

Developing a plan of action is a subsequent step in the ethical reasoning process, following the identification of the problem and consideration of possible alternatives. Once the nurse has evaluated the outcomes of various options, they can formulate a plan that outlines the chosen course of action and its implementation steps.

D) Identify the problem:

Identifying the problem is the first step in the ethical reasoning process. This involves recognizing the presence of an ethical dilemma or issue that requires resolution. By clearly defining the problem, the nurse can begin to explore relevant ethical principles, values, and considerations to guide decision-making and problem-solving.

A. Place the client close to the nurses' station. B. Cover the site with a stockinette dressing. C. Administer a sedative. D. Apply a soft mitten restraint.

Correct Answer is D

Explanation

A) Place the client close to the nurses' station:

While placing the client closer to the nurses' station may enhance supervision and monitoring, it does not address the immediate safety concern of preventing the client from removing the IV catheter again. This action may be considered after implementing measures to prevent further self-harm.

B) Cover the site with a stockinette dressing:

Covering the site with a dressing is important for maintaining a sterile environment around the IV site. However, if the client is disoriented and has already removed the IV catheter, simply covering the site may not prevent further attempts to remove it. Addressing the underlying issue of the client's behavior is necessary.

C) Administer a sedative:

Administering a sedative may be appropriate in certain situations to calm an agitated or disoriented client. However, it should not be the first action taken after observing the reinsertion of the IV catheter. Sedation should be used judiciously and only after other interventions to ensure the client's safety have been attempted.

D) Apply a soft mitten restraint:

This is the most appropriate action to prevent the client from removing the IV catheter again. A soft mitten restraint limits the client's ability to access the IV site while allowing some movement and comfort. It is a temporary measure to ensure the safety of the client and the integrity of the IV line until further assessment and interventions can be implemented.

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A nurse on a telemetry unit is assisting with the plan of care for a client who has pulmonary edema. Which of the following instructions should the nurse include in the plan of care?

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