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. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.
B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.
C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.
D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.
Correct Answer is A
Explanation
Rationale:
A. Assisting with deep breathing and coughing is the priority action. This is crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially following abdominal surgery. Deep breathing exercises can help expand the lungs and promote ventilation.
B. Monitoring the incision site for signs of infection is important, but it is not the immediate priority. The client’s respiratory function takes precedence in the early postoperative period.
C. Assessing fluid intake is important for overall recovery, but it is not as critical as ensuring the client can breathe effectively and prevent complications.
D. While ambulation is beneficial for recovery and preventing complications such as deep vein thrombosis, the nurse must first ensure the client can manage their airway and breathing.