The nurse in the intensive care unit is caring for a client with left-sided heart failure and pulmonary edema as a complication.
The nurse identifies a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.
Which of the following interventions would be considered the least priority according to the nursing diagnosis?
Providing a pressure reducing mattress.
Administering oxygen and monitoring for dry nasal mucus membranes.
Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer.
Placing the client in Fowler’s position.
The Correct Answer is A
Choice A rationale
Providing a pressure-reducing mattress, while important for preventing pressure ulcers, is not directly related to improving gas exchange in the lungs. Therefore, it would be considered the least priority intervention for a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.
Choice B rationale
Administering oxygen and monitoring for dry nasal mucus membranes is a crucial intervention for a patient with impaired gas exchange. Oxygen therapy can help increase the amount of oxygen in the blood and alleviate symptoms of hypoxemia.
Choice C rationale
Encouraging the client to turn, deep breathe, cough, and use the incentive spirometer can help improve lung ventilation, promote the clearance of secretions, and prevent atelectasis, thereby improving gas exchange.
Choice D rationale
Placing the client in Fowler’s position can help improve lung expansion and gas exchange by reducing pressure on the diaphragm, making it easier for the patient to breathe.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.
Correct Answer is D
Explanation
Choice A rationale
The diaphragm is not typically the location of a coarctation of the aorta. The diaphragm is a muscle that helps with breathing and separates the chest cavity from the abdominal cavity.
Choice B rationale
The bifurcation into the common iliac arteries is not typically the location of a coarctation of the aorta. The common iliac arteries are located in the lower part of the aorta and supply blood to the pelvis and legs.
Choice C rationale
The aortic valve is not typically the location of a coarctation of the aorta. The aortic valve is located between the left ventricle of the heart and the aorta.
Choice D rationale
The ductus arteriosus is the correct answer. Coarctation of the aorta often occurs near the ductus arteriosus, a blood vessel that connects the left pulmonary artery to the aorta.
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