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 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.
Correct Answer is C
Explanation
Choice A reason : Methadone is an opioid used primarily for opioid maintenance therapy and to relieve severe pain, not typically for alcohol withdrawal. It does not address the specific symptoms associated with alcohol withdrawal such as seizures or delirium tremens¹.
Choice B reason : Salicylates, such as aspirin, are not used to treat alcohol withdrawal. They can increase the risk of bleeding, especially in the gastrointestinal tract, which can be a concern in individuals with a history of heavy alcohol use¹.
Choice C reason : Benzodiazepines, such as chlordiazepoxide, are the first-line treatment for alcohol withdrawal. They help reduce the risk of seizures, ease withdrawal symptoms, and can prevent the progression to more severe forms of withdrawal such as delirium tremens¹².
Choice D reason : Diphenhydramine is an antihistamine with sedative properties, but it is not a first-line medication for alcohol withdrawal. While it may provide some sedation, it does not prevent seizures or other serious complications of alcohol withdrawal¹.
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