A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning.
The nurse should recognize these assessment findings as indicating which of the following?
Increased cardiac output.
Pleural effusion.
Fluid volume excess.
Aspiration.
The Correct Answer is C
“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess.
Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Initiate a referral for the client to a home health agency.
This action demonstrates client advocacy because it empowers the client to continue self-care at home while also providing them with additional support and resources through the home health agency.
Choice A is wrong because avoiding large crowds of people is a precautionary measure but does not demonstrate client advocacy.
Choice B is wrong because avoiding raw vegetables is a dietary recommendation but does not demonstrate client advocacy.
Choice C is wrong because reminding the client of the importance of medication adherence is important but does not demonstrate client advocacy.
Correct Answer is B
Explanation
- A. "You should ask your provider about your plan." This response is appropriate because it acknowledges the client's desire to explore alternative treatments while directing them to the appropriate source for medical advice. It promotes client autonomy and ensures they receive accurate information from their healthcare provider.
- B. "Tell me what you know about chemotherapy." This response is also appropriate. It encourages the client to express their understanding and concerns about chemotherapy, allowing the nurse to identify any misconceptions and provide accurate information. This also opens the door for the client to express their concerns about vitamins and minerals, and why they want to persue that treatment.
- C. "I have never heard of any holistic treatment that is effective." This response is inappropriate because it dismisses the client's preferences and demonstrates a lack of respect for their autonomy. It also displays a lack of knowledge, as some holistic treatments can be used as supportive therapies.
- D. "The best way to treat your cancer is chemotherapy." This response is inappropriate because it is directive and does not allow the client to participate in decision-making. It also does not address the client's desire to explore alternative treatments.
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