Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Assessing blood pressure.

Measuring intake and output.

Elevating the head of the bed.

Checking for presence of dependent edema.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assessing blood pressure monitors fluid overload but doesn’t immediately reduce respiratory strain. Elevating the head of the bed improves breathing, making this incorrect, as it’s less urgent than the nurse’s first action to prevent harm from fluid overload.

Choice B reason: Measuring intake and output tracks fluid balance but is less immediate than elevating the bed to ease breathing. This is incorrect, as it delays the nurse’s priority action to alleviate respiratory distress in a client with suspected fluid overload.

Choice C reason: Elevating the head of the bed is the first action to reduce respiratory distress in fluid overload by decreasing venous return. This aligns with acute care priorities, making it the correct action to prevent harm in the client with suspected hypervolemia.

Choice D reason: Checking for dependent edema confirms fluid overload but doesn’t address immediate respiratory risks. Elevating the bed is urgent, making this incorrect, as it’s secondary to the nurse’s first action to improve breathing in the fluid-overloaded client.

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Correct Answer is D

Explanation

Choice A reason: Seizure precautions are relevant but secondary to establishing IV access for antihypertensive administration in hypertensive crisis. Starting an IV enables immediate treatment, making this incorrect, as it delays the critical intervention needed to lower the client’s dangerously high blood pressure.

Choice B reason: Instructing to report vision changes monitors complications but doesn’t address the urgent need to lower blood pressure. IV access facilitates medication delivery, making this incorrect, as it postpones the primary action for managing the client’s hypertensive crisis effectively.

Choice C reason: Elevating the bed may reduce intracranial pressure but is less urgent than starting an IV for antihypertensive drugs. IV access is the priority, making this incorrect, as it delays the critical intervention to manage the client’s severe hypertension in the emergency department.

Choice D reason: Starting a peripheral IV is the first action to enable rapid administration of antihypertensive medications in hypertensive crisis. This aligns with emergency care protocols for blood pressure 254/139 mm Hg, making it the correct initial step to stabilize the client’s condition.

A. “Until your incision is healed, do not submerge your pacemaker. Only take showers.” B. “Report any pulse rates lower than your pacemaker settings.” C. “If you feel weak, apply pressure over your generator.” D. “Have your pacemaker turned off before having magnetic resonance imaging (MRI).” E. “Do not lift your left arm above the level of your shoulder for 8 weeks.”

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Avoiding submersion until the incision heals prevents infection in a new pacemaker site. This aligns with post-implant care, making it a correct instruction the nurse would include to ensure proper healing and device safety for the client.

Choice B reason: Reporting pulse rates below pacemaker settings indicates potential device failure, requiring prompt evaluation. This aligns with pacemaker monitoring, making it a correct instruction the nurse would teach the client to ensure device function and cardiac stability.

Choice C reason: Applying pressure over the generator doesn’t address weakness and may harm the device. Reporting low pulse rates is correct, making this incorrect, as it’s not a valid instruction for the nurse to include in pacemaker teaching.

Choice D reason: Pacemakers aren’t turned off for MRI; MRI-compatible devices or alternatives are used. Arm movement restriction is correct, making this incorrect, as it’s inaccurate compared to the nurse’s proper instructions for pacemaker care and MRI safety.

Choice E reason: Avoiding arm lifting above the shoulder for 8 weeks prevents lead dislodgement in a new pacemaker. This aligns with post-implant restrictions, making it a correct instruction the nurse would include to protect the device’s integrity.

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Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client’s teaching? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

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