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A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

A.

Bradycardia

B.

Wheezing

C.

Pale, Dry Skin

D.

Pink, frothy sputum

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Rationale:

A. While restricting visits from young children may help reduce infection risk, it is not a sufficient or specific intervention for neutropenic precautions.

B. Avoiding raw fruits is critical because they can harbor bacteria and increase the risk of infection in neutropenic clients. Cooked fruits are safer options.

C. Measuring temperature should occur more frequently than every 8 hours, ideally every 4 hours or more, to quickly identify fever, a sign of infection.

D. Disposable gloves should be used from within the client's room to maintain strict infection control measures; using gloves from outside could introduce contaminants.

Correct Answer is ["B","C","D"]

Explanation

Rationale:

A. Assessing a client requires clinical judgment and should not be delegated to an AP.

B. Accompanying a client to occupational therapy is a task that can be safely assigned to an AP as it does not require clinical judgment.

C. Checking the position of a client in soft wrist restraints is a routine task that can be assigned to an AP as long as the AP has been trained in restraint protocols.

D. Sitting with a client who has alcohol use disorder (5 days after their last drink) is a task that an AP can perform, especially if the client does not require close monitoring for medical complications such as delirium tremens.

E. Setting limits with a client requires therapeutic communication skills and clinical judgment, so this should not be delegated to an AP.

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