The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the healthcare provider and prepares to implement which priority interventions? (Select all that apply.)

Administering morphine sulfate intravenously

Administering oxygen

Transporting the client to the coronary care unit

Placing the client in a low Fowler's side-lying position

Inserting a Foley catheter

Administering furosemide (Lasix)

Answer and Explanation

Correct Answer : A,B,C,E,F

Choice A reason : Morphine sulfate is used intravenously in acute heart failure with pulmonary edema because it can reduce preload and afterload, thereby decreasing the work of the heart and improving breathing.

Choice B reason : Administering oxygen is crucial for a client with pulmonary edema to improve oxygenation and relieve symptoms of hypoxia.

Choice C reason : Transporting the client to the coronary care unit is appropriate for continuous monitoring and management of acute heart failure and pulmonary edema.

Choice D reason : While placing the client in a high Fowler's position is recommended to ease breathing, the low Fowler's side-lying position is not typically indicated for pulmonary edema. Therefore, this choice is incorrect.

Choice E reason : Inserting a Foley catheter can help monitor urine output, especially important when administering diuretics like furosemide, and manage fluid status.

Choice F reason : Administering furosemide (Lasix), a diuretic, helps to reduce fluid overload and relieve pulmonary congestion in clients with heart failure and pulmonary edema.

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Correct Answer is B

Explanation

Choice A reason : While it is important to assure the client, the nurse must first verify that there is a formal DNR order in place to legally honor the client's wishes¹².

Choice B reason : Checking for a DNR order in the medical record is the correct action to ensure that the client's wishes regarding resuscitation are documented and will be followed by all healthcare providers¹².

Choice C reason : Asking about a healthcare proxy is important, but it is secondary to confirming that the client's wishes are documented in the medical record through a DNR order or advance directives¹².

Choice D reason : Verifying a signed copy of the advance directives is crucial, but the immediate step is to check for a DNR order, which is specifically related to the client's request not to be resuscitated¹².

A. Methadone B. Salicylate C. Benzodiazepines D. Diphenhydramine

Correct Answer is C

Explanation

Choice A reason : Methadone is an opioid used primarily for opioid maintenance therapy and to relieve severe pain, not typically for alcohol withdrawal. It does not address the specific symptoms associated with alcohol withdrawal such as seizures or delirium tremens¹.

Choice B reason : Salicylates, such as aspirin, are not used to treat alcohol withdrawal. They can increase the risk of bleeding, especially in the gastrointestinal tract, which can be a concern in individuals with a history of heavy alcohol use¹.

Choice C reason : Benzodiazepines, such as chlordiazepoxide, are the first-line treatment for alcohol withdrawal. They help reduce the risk of seizures, ease withdrawal symptoms, and can prevent the progression to more severe forms of withdrawal such as delirium tremens¹².

Choice D reason : Diphenhydramine is an antihistamine with sedative properties, but it is not a first-line medication for alcohol withdrawal. While it may provide some sedation, it does not prevent seizures or other serious complications of alcohol withdrawal¹.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?

Correct Answer is C

Explanation

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

A nurse is preparing a client who is to receive chemotherapy for the treatment of breast cancer. Which of the following actions should the nurse plan to take?

Which patient is most likely experiencing a pulmonary embolism (PE)?

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

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A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?

A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.)