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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Auscultate the lungs for evidence of wheezing: Lung auscultation is helpful in assessing respiratory status, but evaluating oxygen saturation is more urgent in this situation. It provides an immediate, objective measure of gas.

B. Quickly administer scheduled medications: Administering medications without assessing the client’s respiratory status may be unsafe. The client’s posture and breathing pattern suggest respiratory distress, which should be evaluated before giving medications.

C. Ask the client if an anxiolytic is needed: Anxiety may worsen breathing, but the client’s body language likely indicates a physiological rather than psychological problem. Assessing oxygenation is more important than addressing anxiety in this context.

D. Evaluate the client’s oxygen saturation: Pursed-lip breathing and forward-leaning posture are compensatory mechanisms seen in respiratory distress, often in clients with COPD. Assessing oxygen saturation immediately helps determine the severity of hypoxia and guides appropriate interventions.

A. Confirm that a family member also knows how to administer the medication. B. Document the client's plans to fill the prescription on the discharge teaching plan. C. Explain the importance of obtaining the medication before leaving the hospital. D. Schedule a follow-up visit with the healthcare provider for one week after discharge.

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.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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