The nurse in the intensive care unit is caring for a client with left-sided heart failure and pulmonary edema as a complication.
The nurse identifies a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.
Which of the following interventions would be considered the least priority according to the nursing diagnosis?
Providing a pressure reducing mattress.
Administering oxygen and monitoring for dry nasal mucus membranes.
Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer.
Placing the client in Fowler’s position.
The Correct Answer is A
Choice A rationale
Providing a pressure-reducing mattress, while important for preventing pressure ulcers, is not directly related to improving gas exchange in the lungs. Therefore, it would be considered the least priority intervention for a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.
Choice B rationale
Administering oxygen and monitoring for dry nasal mucus membranes is a crucial intervention for a patient with impaired gas exchange. Oxygen therapy can help increase the amount of oxygen in the blood and alleviate symptoms of hypoxemia.
Choice C rationale
Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer can help improve lung ventilation, promote the clearance of secretions, and prevent atelectasis, thereby improving gas exchange.
Choice D rationale
Placing the client in Fowler’s position can help improve lung expansion and gas exchange by reducing pressure on the diaphragm, making it easier for the patient to breathe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Left heart failure is a common cause of right heart failure. When the left side of the heart is unable to pump blood efficiently, it can cause increased pressure in the lungs, which can then lead to right heart failure.
Choice B rationale
Pericarditis, an inflammation of the sac-like covering around the heart, is not typically a direct cause of right heart failure.
Choice C rationale
While hypertension, or high blood pressure, can contribute to heart failure, it typically affects the left side of the heart more than the right.
Choice D rationale
Acute pneumonia, an infection that inflames the air sacs in one or both lungs, is not typically a direct cause of right heart failure.
Correct Answer is B
Explanation
Choice A rationale
A pleural friction rub, which is a grating sound caused by the inflammation of the pleural surfaces during respiration, is not typically associated with cardiac tamponade. It is more commonly associated with conditions affecting the lungs, such as pneumonia or pleurisy.
Choice B rationale
Distended neck veins are a classic sign of cardiac tamponade. This occurs due to increased pressure in the right atrium as a result of the impaired filling of the ventricles. This is a critical sign that should be reported immediately.
Choice C rationale
Widening pulse pressure (an increase in the difference between systolic and diastolic blood pressure) is not typically associated with cardiac tamponade. In fact, cardiac tamponade more commonly presents with a narrowed pulse pressure.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of cardiac tamponade. More commonly, tachycardia, or a fast heart rate, is observed in response to decreased cardiac output.
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.