A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Pink, frothy sputum
Bradycardia
Flushed, dry skin
Wheezing
The Correct Answer is A
- A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.
- B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.
- C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.
- D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Advocacy is a leadership role that helps others to self-actualize.
- A. Advocacy is a leadership role that helps others to self-actualize. This statement is true and reflects one of the core principles of advocacy, which is to empower others to achieve their full potential and exercise their rights and responsibilities. This choice is correct.
- B. Subordinates are advocates for the nurse manager. This statement is false and contradicts one of the core principles of advocacy, which is to act in the best interest of those who are vulnerable or oppressed, not those who are in positions of power or authority. This choice is incorrect.
- C. Advocacy encourages clients to rely on health care staff for decision-making. This statement is false and contradicts one of the core principles of advocacy, which is to respect and support clients' autonomy and self-determination, not to impose or influence their choices or actions. This choice is incorrect.
- D. Nurse managers should distrust people who expose inappropriate professional practices. This statement is false and contradicts one of the core principles of advocacy, which is to promote and uphold ethical standards and quality of care, not to conceal or ignore malpractice or misconduct. This choice is incorrect.
Correct Answer is C
Explanation
- A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
- B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
- C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
- D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.
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