A nurse is caring for a client who has been admitted to the medical surgical unit.
Edema of the extremities
Jugular vein distention
Tachypnea
Ascites
Pink frothy sputum
Atelectasis
Correct Answer : A,B,C,E
A. Edema of the extremities
Fluid accumulation due to poor cardiac output contributes to peripheral edema.
B. Jugular vein distention
Reflects elevated central venous pressure from fluid overload.
C. Tachypnea
Increased respiratory rate is a compensatory mechanism for impaired oxygen exchange.
D. Ascites
Associated with liver disease or right-sided heart failure, not specifically pulmonary edema.
E. Pink frothy sputum
Classic sign of pulmonary edema due to fluid in the alveoli.
F. Atelectasis
Can occur in respiratory illness but is not a hallmark sign of pulmonary edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Flushing
More common in allergic reactions than circulatory overload.
B. Vomiting
Not typically seen with circulatory overload.
C. Dyspnea
Shortness of breath is a hallmark of fluid overload and pulmonary congestion.
D. Bradycardia
Tachycardia, not bradycardia, is more common in overload situations.
Correct Answer is B
Explanation
A. Mental status assessment
Mental status assessments evaluate cognition, mood, orientation—not environmental hazards.
B. Environmental health assessment
This type of question evaluates potential environmental risks, such as toxins or pollutants. Correct.
C. Faith-based assessment
This involves spiritual beliefs, not chemical exposures.
D. Nutritional assessment
Nutritional assessments focus on diet, weight, and nutritional intake, not exposure to toxins.
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