When assessing an older adult client, the nurse finds that the client is experiencing orthopnea and has an oxygen saturation reading of 93% on room air. Auscultation of the lungs reveals crackles and bilateral pedal edema are present. In which order should the nurse implement these actions? (Arrange in the order from first on top to last on the bottom.)

Raise the head of the bed to Fowler's position.

Provide oxygen per nasal cannula.

Administer a prescribed dose of furosemide.

Monitor urinary output.

Answer and Explanation

Correct Answer : A,B,C,D

Rationale:
A. Raise the head of the bed to Fowler's position: This immediately relieves orthopnea by improving lung expansion and reducing the work of breathing. Positioning is a first-line, non-invasive intervention to enhance respiratory comfort.

B. Provide oxygen per nasal cannula: Oxygen improves tissue oxygenation and prevents hypoxia progression. Although the saturation is borderline normal, oxygen can reduce respiratory effort in the context of fluid overload.

C. Administer a prescribed dose of furosemide: Diuretics treat the underlying cause—fluid overload related to possible heart failure. Removing excess fluid will decrease pulmonary congestion and peripheral edema.

D. Monitor urinary output: This evaluates the effectiveness of the diuretic therapy. Adequate urine output indicates that fluid is being removed and helps prevent worsening heart failure or electrolyte imbalance.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

Rationale:

A. Transdermal analgesic: Transdermal analgesics are formulated to relieve localized pain, not itching or inflammation. They do not address the histamine release or immune activity seen in eczema. Using them offers no therapeutic benefit for pruritus.

B. Topical alcohol rub: Alcohol-based products dry out the skin and cause further irritation, which can worsen eczema symptoms. Applying alcohol increases the risk of burning and inflammation. It is not recommended for sensitive or inflamed skin.

C. Topical corticosteroid: Topical corticosteroids reduce skin inflammation by suppressing local immune responses. They are standard treatment for eczema flares with severe itching. These medications soothe the skin and reduce redness and swelling.

D. Oral antihistamine: Antihistamines block histamine, which contributes to allergic itching in eczema. They are useful for controlling pruritus and helping clients rest. Some types, like diphenhydramine, also have sedative effects that reduce nighttime discomfort.

E. Topical scabicide: Scabicides are antiparasitic agents used to treat infestations like scabies, not eczema. They do not relieve allergic itching or inflammation. Their strong chemicals may actually worsen skin irritation in eczema patients.

A. Give the spouse a straw to help facilitate the client's drinking. B. Assist the spouse and carefully give the client small sips of water. C. Ask the spouse to stop and assess the client's swallowing reflex. D. Obtain thickening powder before providing any more fluids.

Correct Answer is C

Explanation

Rationale:

A. Give the spouse a straw to help facilitate the client's drinking: Using a straw can increase aspiration risk in clients with impaired swallowing or facial weakness. It promotes rapid fluid intake, bypassing normal protective reflexes.

B. Assist the spouse and carefully give the client small sips of water: Offering fluids before assessing swallowing can be dangerous. Clients with possible CVA and facial paralysis are at high risk for aspiration pneumonia due to impaired gag and swallow reflexes.

C. Ask the spouse to stop and assess the client's swallowing reflex: This is the safest and most appropriate action. A swallowing assessment helps determine aspiration risk before any oral intake is provided, especially in neurologically impaired clients.

D. Obtain thickening powder before providing any more fluids: Thickened fluids may help prevent aspiration, but they should not be used before confirming the client’s ability to safely swallow. A full assessment is the priority first step.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with eczema is experiencing severe pruritus. Which PRN prescription(s) should the nurse administer? Select all that apply.

Correct Answer is ["C","D"]

Explanation

Correct Answer is C

Explanation

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