A client arrives on the cardiac unit from the emergency room with a diagnosis of heart failure exacerbation. The nurse receives the client who is acutely short of breath with respiratory rate of 40, pulse oximetry 85%, blood pressure 150/90, and lower extremity swelling. What intervention or action should the nurse take first?

Ensure the client is sitting in an upright position.

Call the respiratory therapist in anticipation of intubating the client.

Prepare to place a Foley catheter in anticipation of giving Lasix.

Apply oxygen.

Answer and Explanation

The Correct Answer is D

Choice A reason: Sitting upright improves breathing but doesn’t address the critical hypoxia indicated by 85% pulse oximetry. Applying oxygen directly corrects low oxygen levels, making this secondary and incorrect compared to the nurse’s priority of ensuring adequate oxygenation in a heart failure exacerbation.

Choice B reason: Calling for intubation anticipates worsening but is premature without first addressing hypoxia with oxygen. Applying oxygen is the immediate need, making this incorrect, as it bypasses the initial step of improving oxygenation in the client with severe respiratory distress.

Choice C reason: Preparing for a Foley catheter anticipates diuresis but doesn’t address the urgent hypoxia at 85% oxygen saturation. Applying oxygen is critical, making this incorrect, as it delays the primary intervention needed to stabilize the client’s respiratory status in heart failure.

Choice D reason: Applying oxygen is the first action to correct hypoxia (pulse oximetry 85%), improving tissue oxygenation in heart failure exacerbation. This aligns with acute care priorities, making it the correct intervention to address the client’s immediate respiratory distress and low oxygen saturation effectively.

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Correct Answer is C

Explanation

Choice A reason: Assessing blood pressure monitors fluid overload but doesn’t immediately reduce respiratory strain. Elevating the head of the bed improves breathing, making this incorrect, as it’s less urgent than the nurse’s first action to prevent harm from fluid overload.

Choice B reason: Measuring intake and output tracks fluid balance but is less immediate than elevating the bed to ease breathing. This is incorrect, as it delays the nurse’s priority action to alleviate respiratory distress in a client with suspected fluid overload.

Choice C reason: Elevating the head of the bed is the first action to reduce respiratory distress in fluid overload by decreasing venous return. This aligns with acute care priorities, making it the correct action to prevent harm in the client with suspected hypervolemia.

Choice D reason: Checking for dependent edema confirms fluid overload but doesn’t address immediate respiratory risks. Elevating the bed is urgent, making this incorrect, as it’s secondary to the nurse’s first action to improve breathing in the fluid-overloaded client.

A. “If my stockings feel tight, I’ll just roll them down for a while.” B. “I’ll put on my elastic stockings at the first sign of swelling.” C. “When I sit down to watch television, I’ll be sure to put my feet up.” D. “It is okay to cross my legs as long as it is less than one hour.”

Correct Answer is C

Explanation

Choice A reason: Rolling down tight stockings creates a tourniquet effect, worsening venous insufficiency. Elevating feet improves circulation, making this incorrect, as it reflects a misunderstanding of compression therapy compared to the correct management taught by the nurse for venous insufficiency.

Choice B reason: Putting on stockings after swelling begins is less effective than wearing them preventatively. Elevating feet reduces edema, making this incorrect, as it shows partial understanding compared to the proactive elevation strategy indicating full comprehension of the nurse’s teaching.

Choice C reason: Elevating feet when sitting promotes venous return, reducing edema in venous insufficiency. This aligns with self-care education for the condition, making it the correct statement, as it demonstrates the client’s accurate understanding of the nurse’s teaching to manage lower extremity swelling.

Choice D reason: Crossing legs impairs venous return, exacerbating venous insufficiency, regardless of duration. Elevating feet is correct, making this incorrect, as it reflects a misconception about safe practices compared to the nurse’s teaching on managing venous insufficiency effectively.

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Naxlex Comprehensive Predictor Exams

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

The nurse is taking care of a 60-year-old client who is scheduled for open reduction internal fixation of the left femur. Which ethical principle is most important when soliciting informed consent from the patient?

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