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 B
Explanation
Chronic stable angina, also known as angina pectoris, is a type of chest pain that occurs when the heart muscle doesn’t get enough oxygen. It is often triggered by physical activity or emotional stress and is usually relieved by rest or medication such as nitroglycerin. Therefore, a patient statement that the pain goes away after taking a nitroglycerin tablet would help confirm a previous diagnosis of chronic stable angina.
Correct Answer is B
Explanation
Choice A rationale
Evaluating the need for smoking cessation is a standard part of nursing care, especially for patients with circulatory issues. Smoking can exacerbate circulatory problems and delay wound healing.
Choice B rationale
Applying TED hose to both legs might not be appropriate for this patient. TED hose are compression stockings designed to prevent deep vein thrombosis and promote circulation. However, in a patient with weak pedal pulses and a full-thickness wound on the leg, the compression from the stockings could potentially worsen circulation to the area and impede wound healing.
Choice C rationale
Consulting with physical therapy could be beneficial for this patient. Physical therapists can provide exercises and interventions to improve circulation and mobility, which could help with the patient’s circulatory issues and wound healing.
Choice D rationale
Obtaining an Ankle-Brachial Index (ABI) using a hand-held Doppler could be useful in this situation. The ABI is a simple, non-invasive test that can help diagnose peripheral artery disease (PAD), a condition that could be causing the patient’s weak pedal pulses and wound healing issues.
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