The nurse is assessing a client who is admitted with left-sided heart failure. Which finding indicates that the client is progressing into pulmonary edema?
Fever of 102.2°F (39°C).
Hacking, dry cough.
Peripheral pitting edema.
Bilateral crackles in all lung fields.
The Correct Answer is D
A. Fever of 102.2°F (39°C): A fever may suggest an infectious process such as pneumonia but is not a hallmark of pulmonary edema. While infection can exacerbate heart failure, the presence of fever alone does not indicate pulmonary fluid accumulation.
B. Hacking, dry cough: A dry cough may be an early symptom of left-sided heart failure, but it is nonspecific and does not confirm pulmonary edema. As fluid accumulates, the cough becomes productive and is accompanied by other symptoms like dyspnea and crackles.
C. Peripheral pitting edema: Peripheral edema is more closely associated with right-sided heart failure. Although some clients with left-sided failure can develop right-sided symptoms, peripheral edema does not directly signal pulmonary congestion or edema.
D. Bilateral crackles in all lung fields: Crackles heard throughout the lung fields indicate fluid in the alveoli, a defining feature of pulmonary edema. This finding signifies worsening left-sided heart failure and impaired gas exchange, requiring prompt medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Confirm that a family member also knows how to administer the medication:
It is helpful for family members to be informed, but the priority is ensuring the client has immediate access to nitroglycerin.
B. Document the client's plans to fill the prescription on the discharge teaching plan:
Documentation is important, but it does not address the urgent need for access to medication. Relying on post-discharge mail delivery may result in a delay that compromises the client’s safety.
C. Explain the importance of obtaining the medication before leaving the hospital:
Nitroglycerin is used for the rapid relief of chest pain and must be readily available at all times. Clients should not leave the hospital without this critical rescue medication.
D. Schedule a follow-up visit with the healthcare provider for one week after discharge:
While follow-up is essential for monitoring treatment efficacy and adjustments, it does not resolve the immediate need for having nitroglycerin accessible in case of angina.
Correct Answer is C
Explanation
A. Deficient knowledge related to a new medication regimen: While client education is important, it is not the most immediate concern during thrombolytic therapy. Safety risks such as bleeding take priority during the acute phase of care.
B. Activity intolerance related to ischemia: Activity may be limited following an AMI, but thrombolytic therapy is administered while the client is on bedrest. Managing activity intolerance becomes more relevant during recovery and rehabilitation, not during acute treatment.
C. Risk for injury related to effects of thrombolytics: Thrombolytic agents carry a high risk for bleeding, including potentially life-threatening intracranial hemorrhage or gastrointestinal bleeding. Monitoring for signs of bleeding is critical and the most relevant nursing problem.
D. Ineffective breathing pattern related to adverse drug effects: Thrombolytics are not commonly associated with respiratory compromise. Unless the client has pulmonary edema or another respiratory condition, this diagnosis is not supported by the effects of thrombolytic therapy.
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