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 B

Explanation

Choice A reason: Initiating antibiotics is critical but follows cultures to identify the causative organism. Obtaining cultures first ensures accurate treatment, making this incorrect, as it risks altering culture results if antibiotics are given before sampling in the pneumonia client.

Choice B reason: Obtaining blood and sputum cultures first identifies the pneumonia-causing organism, guiding effective antibiotic therapy. This aligns with infection management protocols, making it the correct initial order to implement for the client admitted with pneumonia to ensure accurate treatment.

Choice C reason: Airborne precautions are needed for specific pneumonias (e.g., tuberculosis), but most require droplet precautions. Cultures guide treatment, making this incorrect, as it’s less urgent than obtaining cultures first to confirm the pathogen in the client with pneumonia.

Choice D reason: An indwelling catheter is unnecessary for pneumonia unless urinary retention is present. Obtaining cultures is the priority, making this incorrect, as it’s irrelevant to the immediate management of the client’s infection compared to identifying the causative organism.

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 is admitting a client with pneumonia. Which of the following orders should be implemented first?

Correct Answer is B

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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