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 A
Explanation
Choice A reason : Individuals with OCD often engage in compulsive behaviors, such as picking up after others, to make their environment feel more controlled or tolerable. This behavior is a response to the anxiety produced by their obsessions, which in this case, could be related to cleanliness or order¹. By controlling their immediate environment, they may feel a temporary relief from their anxiety, even though this relief is often short-lived and the compulsion becomes a repetitive cycle².
Choice B reason : Changing tasks is not typically the goal of compulsive behaviors in OCD. These behaviors are usually very specific and are performed to manage the anxiety associated with particular obsessions. While the individual might switch from one compulsive behavior to another, it is not done with the intention of task variation but rather as a response to shifting obsessive thoughts¹.
Choice C reason : Compulsive behaviors in OCD are not aimed at increasing social interaction. In fact, these behaviors can often interfere with social activities and relationships, as they can be time-consuming and may make the individual feel embarrassed or ashamed, leading to social isolation².
Choice D reason : Compulsive behaviors can sometimes be a way for individuals with OCD to exert control over other behaviors or thoughts. However, the primary function of these behaviors is to manage the anxiety associated with obsessions, not necessarily to control other unrelated behaviors¹.
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