The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the healthcare provider and prepares to implement which priority interventions? (Select all that apply.)
Administering morphine sulfate intravenously
Administering oxygen
Transporting the client to the coronary care unit
Placing the client in a low Fowler's side-lying position
Inserting a Foley catheter
Administering furosemide (Lasix)
Correct Answer : A,B,C,E,F
Choice A reason : Morphine sulfate is used intravenously in acute heart failure with pulmonary edema because it can reduce preload and afterload, thereby decreasing the work of the heart and improving breathing.
Choice B reason : Administering oxygen is crucial for a client with pulmonary edema to improve oxygenation and relieve symptoms of hypoxia.
Choice C reason : Transporting the client to the coronary care unit is appropriate for continuous monitoring and management of acute heart failure and pulmonary edema.
Choice D reason : While placing the client in a high Fowler's position is recommended to ease breathing, the low Fowler's side-lying position is not typically indicated for pulmonary edema. Therefore, this choice is incorrect.
Choice E reason : Inserting a Foley catheter can help monitor urine output, especially important when administering diuretics like furosemide, and manage fluid status.
Choice F reason : Administering furosemide (Lasix), a diuretic, helps to reduce fluid overload and relieve pulmonary congestion in clients with heart failure and pulmonary edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Constipation is not commonly reported as an adverse effect of tamoxifen. While it may occur, it is not as prevalent as other side effects such as hot flashes¹.
Choice B reason : Hot flashes are a well-known and common adverse effect of tamoxifen. They occur due to the antiestrogen effects of the medication, which can disrupt the body's temperature regulation¹.
Choice C reason : Increased appetite is not typically associated with tamoxifen use. While changes in weight can occur, they are not directly linked to an increase in appetite as a side effect of this medication¹.
Choice D reason : Insomnia may occur in some individuals taking tamoxifen, but it is not one of the most common adverse effects. Hot flashes and other menopausal-like symptoms are more frequently reported¹.
Correct Answer is C
Explanation
Choice A reason : Bubbling in the water seal chamber with exhalation can be a normal finding as it indicates that air is being evacuated from the pleural space. However, continuous bubbling may suggest an air leak, which should be evaluated.
Choice B reason : The visibility of the eyelets is not typically a concern unless the tube is dislodged. If the chest tube is functioning properly and the eyelets are meant to be within the chest cavity, their visibility might indicate dislodgement.
Choice C reason : Crepitus, or subcutaneous emphysema, can occur if air leaks into the tissue surrounding the insertion site. This can be a sign of a problem with the chest tube placement or function and should be reported to the provider immediately.
Choice D reason : Movement of the trachea toward the unaffected side, or tracheal deviation, can be a sign of tension pneumothorax, a life-threatening condition that requires immediate attention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.