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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Implementing a smoking cessation program, while beneficial for overall health and cardiovascular risk reduction, is not the primary therapeutic goal for secondary hypertension. Secondary hypertension is high blood pressure caused by an underlying condition. Therefore, the primary goal is to treat the underlying condition.
Choice B rationale
Treating the specific etiological disease is the primary therapeutic goal for secondary hypertension. By treating the underlying cause, blood pressure can often be lowered or returned to normal.
Choice C rationale
Initiating a rapid weight-loss program is not the primary therapeutic goal for secondary hypertension. While weight loss can help lower blood pressure in general, the primary goal in secondary hypertension is to treat the underlying cause.
Choice D rationale
Starting a rigorous exercise regimen, while beneficial for overall health and cardiovascular risk reduction, is not the primary therapeutic goal for secondary hypertension. The primary goal is to treat the underlying condition causing the high blood pressure.

A. Sinus tachycardia. B. Ventricular tachycardia. C. Ventricular fibrillation. D. Atrial flutter.

Correct Answer is B

Explanation

Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the primary therapeutic goal for secondary hypertension?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A newborn frequently experiences cyanosis, typically during crying or after feeding. Which cardiac diagnosis is supported by this history?

When assessing a male patient in the telemetry unit who is experiencing persistent, crushing chest pain, which symptoms would lead the nurse to suspect a myocardial infarction?

A patient newly admitted with pulmonary edema is due to receive several medications. Which medication should the nurse efore administration?

What is the primary pathophysiological reason for performing Coronary Artery Bypass Surgery?

A nurse is caring for a patient who has undergone an angiogram. What should the nurse prioritize in assessing and documenting for this patient?

A nurse is providing care for a patient who has weak pedal pulses, no hair on both legs, and a full-thickness wound on the right lateral malleolus with defined margins, which includes a small amount of serous exudate. Which intervention should not be performed?

The nurse is providing care for a patient with the following tracing on the electrocardiogram (ECG) for atrial fibrillation. What prescription should the nurse anticipate from the primary healthcare provider (PHCP)?

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?