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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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

"Gather enough supplies to last for 2 weeks": This information is essential for disaster preparedness. During emergencies, such as natural disasters or pandemics, access to resources may be limited for an extended period. Having a sufficient supply of food, water, medications, and other essentials for at least two weeks ensures that older adults can sustain themselves until assistance becomes available.

C) "Have a backup supply of nonprescription medications": It is crucial for older adults to have a backup supply of nonprescription medications, such as pain relievers, antacids, or allergy medications, in case they are unable to access pharmacies during a disaster. Having these medications readily available can help manage common health issues that may arise during emergencies.

D) "Stock 2 liters of water per person per day": Adequate hydration is essential for maintaining health, especially during emergencies when access to clean water may be disrupted. Older adults are particularly vulnerable to dehydration, so having a sufficient supply of water—approximately 2 liters per person per day—for drinking, cooking, and hygiene purposes is critical for their well-being.

A. ADL B. SQ C. AU D. HS

Correct Answer is A

Explanation

A) ADL (Activities of Daily Living): This abbreviation is commonly used in healthcare documentation to refer to the routine tasks individuals perform independently for self-care, such as bathing, dressing, grooming, and toileting. Reminding the newly licensed nurse to use the abbreviation ADL ensures clear and concise documentation of the client's functional status and care needs.

B) SQ: While SQ could stand for subcutaneous (as in SQ injection), it's generally recommended to use the full term "subcutaneous" in documentation to avoid confusion or misinterpretation. Using abbreviations like SQ can lead to errors or miscommunication in healthcare settings.

C) AU: This abbreviation typically stands for "each ear" when documenting information related to the ears, such as when administering eardrops or assessing for symptoms. However, similar to SQ, it's preferable to use the full term "each ear" in documentation to ensure clarity and avoid ambiguity.

D) HS: HS commonly stands for "hour of sleep" or "at bedtime" when documenting medication administration times. However, like other abbreviations, it's advisable to use the full term "at bedtime" to prevent misunderstandings or errors related to medication dosing schedules.

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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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