A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Bradycardia
Wheezing
Pale, Dry Skin
Pink, frothy sputum
The Correct Answer is D
Rationale:
A. Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.
B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.
C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.
D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.
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Correct Answer is B
Explanation
Rationale:
A. Arterial blood gases (ABGs) are typically used to assess respiratory function and acid-base balance, which are not primary concerns with valproic acid use.
B. Serum liver enzyme levels are critical to monitor due to the risk of hepatotoxicity associated with valproic acid therapy, making this test essential for safe management.
C. A chest X-ray is generally used to assess respiratory conditions, not relevant for monitoring the effects of valproic acid.
D. Urine culture and sensitivity are used to diagnose urinary tract infections and are not relevant to the monitoring of valproic acid therapy.
Correct Answer is A
Explanation
Rationale:
A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.
B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.
C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.
D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.