Nokea
A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?
- A. Intubation of the airway
- B. BP and pulse measurements every 15 to 30 minutes
- C. Insertion of a central venous catheter
- D. Hourly administration of a fluid bolus
Correct Answer: B
Rationale: Bedside ECG monitoring is standard, as are continuous pulse oximetry, automatic BP, and pulse measurements approximately every 15 to 30 minutes.
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The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
- A. There is excess fluid volume in the interstitial space in areas affected by gravity.
- B. There is excess fluid volume in the venous system of the lower extremities.
- C. There is excess fluid volume in the arterial system of the lower extremities.
- D. There is excess fluid volume in the hepatic system.
Correct Answer: A
Rationale: Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. The other options are not descriptive of pitting edema.
A client diagnosed with pulmonary edema has a PaCO2 of 72 mm Hg and an oxygen saturation of 84%. What method of oxygen delivery would best meet the needs of this client?
- A. Intubation and mechanical ventilation
- B. Face mask with nonrebreather
- C. Oxygen cannula at 6 L/minute
- D. Venturi mask at 35%
Correct Answer: A
Rationale: The client's respiratory status is severely compromised and has developed signs of respiratory failure. When respiratory failure occurs, the client is intubated and oxygen is administered under continuous positive airway pressure or with mechanical ventilation with positive end-expiratory pressure. A face mask, cannula, or Venturi mask will not deliver the concentration or ventilatory support that an endotracheal tube with mechanical ventilation will provide.
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client?
- A. Low-fat diet
- B. Low-potassium diet
- C. Low-cholesterol diet
- D. Low-sodium diet
Correct Answer: D
Rationale: Medical management of both left-sided and right-sided heart failure is directed at reducing the heart's workload and improving cardiac output primarily through dietary modifications, drug therapy, and lifestyle changes. A low-sodium diet is prescribed, and fluids may be restricted. Because the client will be on a diuretic such as Lasix, he may become potassium depleted and would need potassium in the diet. A low-cholesterol and low-fat diet may be prescribed but are not specific to the heart failure.
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?
- A. The development of chronic obstructive pulmonary disease (COPD)
- B. The development of left-sided heart failure
- C. The development of right-sided heart failure
- D. The development of cor pulmonale
Correct Answer: B
Rationale: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of/left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.
A client is taking furosemide for the treatment of heart failure. What food should the nurse suggest that is rich in potassium?
- A. Pasta
- B. Peanut butter
- C. Coffee
- D. Angel food cake
Correct Answer: B
Rationale: Peanut butter is rich in potassium. Pasta, coffee, and angel food cake are low potassium items.