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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cracked lips are a symptom of Kawasaki disease, but they are more commonly associated with the subacute phase of the disease, not the acute phase.
Choice B rationale
Conjunctival hyperemia, or redness of the whites of the eyes, is a common symptom in the acute phase of Kawasaki disease. It typically presents as bilateral, non-exudative conjunctival injection, primarily in the bulbar conjunctivae.
Choice C rationale
A normal appearance is not typically seen in the acute phase of Kawasaki disease, which is characterized by a high fever and at least four of the five main symptoms, including conjunctival hyperemia.
Choice D rationale
Desquamation of the skin, or peeling, is a symptom of Kawasaki disease, but it typically occurs in the subacute phase, not the acute phase.
Correct Answer is D
Explanation
The symptoms described - tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum - are indicative of acute pulmonary edema, a condition characterized by fluid accumulation in the lungs due to heart failure. In this situation, the Fowler’s position (sitting up at a 45-60 degree angle) with legs lowered is recommended. This position helps to reduce venous return to the heart, thereby decreasing the workload on the heart and helping to alleviate symptoms.
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