The nurse is assessing a hospitalized client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse observes rapid shallow respirations and use of accessory muscles. Which action should the nurse include in the client's plan of care?
Institute a daily fluid restriction while the client is in the hospital.
Teach the client about home blood pressure monitoring methods.
Change intravenous (IV) fluids to a more hypotonic solution.
Prepare the client for an emergency embolectomy.
The Correct Answer is A
A. Institute a daily fluid restriction while the client is in the hospital: In pulmonary edema, fluid overload worsens respiratory symptoms by increasing hydrostatic pressure in the pulmonary circulation. A fluid restriction helps reduce volume overload and relieve dyspnea.
B. Teach the client about home blood pressure monitoring methods: Although blood pressure control is important in heart failure management, this action does not address the client's acute respiratory distress.
C. Change intravenous (IV) fluids to a more hypotonic solution: Changing to hypotonic IV fluids could worsen fluid overload by shifting fluids into the interstitial spaces. Clients with pulmonary edema usually require restricted fluids and possibly diuretics rather than continued IV infusions.
D. Prepare the client for an emergency embolectomy: An embolectomy is indicated for a massive pulmonary embolism. The client's symptoms, such as orthopnea and paroxysmal nocturnal dyspnea, are consistent with fluid overload and left-sided heart failure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. It will no longer be necessary to take daily doses of anticoagulants: Clients with mechanical valves are at high risk for thromboembolism and require lifelong anticoagulation therapy. Stopping anticoagulants places the client at risk for valve thrombosis and systemic emboli such as stroke.
B. The client will need to take an antibiotic before dental procedures: Prophylactic antibiotics are recommended before dental procedures to prevent infective endocarditis in clients with mechanical heart valves.
C. Mechanical valves usually must be replaced within 7 to 10 years after insertion:
Mechanical valves are highly durable and often last 20 years or more. Unlike bioprosthetic valves, they do not require routine replacement unless complications occur.
D. Heparin injections will be required to decrease the incidence of clot formation:
Heparin may be used short-term postoperatively, but long-term anticoagulation for mechanical valves is typically managed with oral agents like warfarin.
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.
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