The nurse is making a home visit to a client with end-stage heart disease. The client has a living will and refuses to ever go back to a hospital. During the visit, the nurse notes that the client is pale and short of breath while speaking. The nurse discovers 3+ pitting edema in both ankles and bilateral pulmonary crackles. Which intervention should the nurse implement first?
Explain the need for hospitalization.
Apply oxygen 2 L/minute via nasal cannula.
Obtain a peripheral oxygen saturation level.
Elevate client's feet above the level of the heart.
The Correct Answer is C
Choice A reason: While hospitalization may be medically indicated, the client has a living will and has explicitly refused hospital care. The nurse must respect the client's autonomy and explore alternative interventions that align with the client's wishes.
Choice B reason: Oxygen therapy may be necessary, but it should be based on objective assessment. Administering oxygen without confirming hypoxia may mask underlying deterioration or lead to inappropriate treatment.
Choice C reason: Obtaining a peripheral oxygen saturation level is the first step in assessing the severity of respiratory compromise. It provides critical data to guide further interventions, including whether oxygen therapy is needed and how urgently.
Choice D reason: Elevating the feet may help reduce peripheral edema but does not address pulmonary congestion or respiratory distress. It is a supportive measure, not a priority intervention in the presence of dyspnea and crackles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: State law governs mandatory reporting requirements for suspected abuse. It provides legal guidance on when and how to report, and protects the nurse from liability when reporting in good faith. Compliance with state law is essential in safeguarding vulnerable populations.
Choice B reason: The ANA Code of Ethics outlines professional responsibilities and moral obligations but does not provide legal mandates or procedures for reporting abuse.
Choice C reason: The Nurse Practice Act defines scope of practice and licensure requirements but does not specifically address abuse reporting protocols.
Choice D reason: Facility procedures may offer internal guidance but cannot override legal obligations. They are secondary to state law in determining the nurse’s duty to report.
Correct Answer is D
Explanation
Choice A reason: Monitoring for disease progression is important but falls under secondary prevention. Tertiary prevention focuses on rehabilitation and optimizing function after disease onset.
Choice B reason: Family history is relevant for risk assessment and primary prevention. Compliance with the medical regimen is important but does not fully address the rehabilitative goals of tertiary care.
Choice C reason: Postoperative wound assessment is part of acute care and early recovery, not long-term rehabilitation. It is more aligned with secondary prevention.
Choice D reason: Evaluating exercise tolerance and psychosocial adaptation supports recovery and reintegration into daily life. These are key components of tertiary prevention, aimed at minimizing disability and improving quality of life.
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