A nurse is caring for a client with pulmonary edema. Which assessment finding should the nurse prioritize when monitoring the client's respiratory status?
Skin temperature and color
Urinary output
Bowel sounds
Peripheral edema
The Correct Answer is A
A) Correct. Skin temperature and color can provide important clues about tissue perfusion and oxygenation, which are critical in pulmonary edema.
B) Incorrect. While urinary output is important, it is not the primary focus when monitoring respiratory status in pulmonary edema.
C) Incorrect. Bowel sounds are unrelated to pulmonary edema and should not be the priority assessment.
D) Incorrect. Peripheral edema may be a sign of fluid retention, but skin color and temperature are more directly related to respiratory status.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Urinary output is important but does not directly assess the client's oxygenation status.
B) Correct. Monitoring the respiratory rate and effort is essential to ensure the client is adequately oxygenated and not in respiratory distress.
C) Incorrect. Skin turgor is unrelated to oxygenation and pulmonary edema.
D) Incorrect. Bowel sounds do not provide information about the client's oxygenation status.
Correct Answer is A
Explanation
A) Correct. Pink, frothy sputum is often referred to as hemoptysis and is a common presentation in pulmonary edema.
B) Incorrect. Orthopnea refers to difficulty breathing when lying flat and is associated with heart failure but is not specifically related to pink, frothy sputum.
C) Incorrect. Paroxysmal nocturnal dyspnea (PND) is another symptom of heart failure but does not involve the coughing up of pink, frothy sputum.
D) Incorrect. Crepitus is a term used to describe a crackling or popping sound and is not directly related to the sputum seen in pulmonary edema.
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