a nurse is caring for a patient with heart failure who has developed pulmonary edema what is the nurses priority action

ATI RN

ATI Capstone Comprehensive Assessment B

1. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

A. Administer a diuretic as prescribed.
B. Place the patient in a high Fowler's position.
C. Administer oxygen via nasal cannula.
D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

2. What are the common side effects of opioid analgesics, and how should they be managed?

A. Drowsiness and dizziness, ensuring safety precautions
B. Respiratory depression, ensuring adequate ventilation
C. Constipation and nausea, managed with stool softeners
D. Nausea and vomiting, managing with antiemetics

Correct answer: A

Rationale: The correct answer is A. Common side effects of opioid analgesics include drowsiness and dizziness. These side effects can impair a person's ability to operate machinery or drive safely. To manage these side effects, it is essential to advise patients to avoid activities that require alertness until they know how the medication affects them. Choices B, C, and D are incorrect because respiratory depression, constipation, and nausea are also common side effects of opioids, but they are not the primary side effects being asked for in this question.

3. How can a healthcare provider prevent pressure ulcers in an immobile patient?

A. Turn the patient every 4 hours.
B. Provide the patient with a special mattress.
C. Elevate the patient's legs to reduce pressure.
D. Limit the patient's movement to reduce friction.

Correct answer: B

Rationale: Providing the immobile patient with a special mattress is an effective way to prevent pressure ulcers. Special mattresses help distribute pressure evenly and reduce the risk of developing pressure ulcers by relieving pressure on sensitive areas. Turning the patient every 4 hours (Choice A) is a standard practice to prevent pressure ulcers but may not be as effective as using a special mattress. Elevating the patient's legs (Choice C) can help with circulation but may not directly prevent pressure ulcers. Limiting the patient's movement (Choice D) can lead to other complications and is not a recommended method for preventing pressure ulcers.

4. What should be done to manage a patient with contact precautions?

A. Wear a mask, gown, and gloves for all patient interactions.
B. Ensure that visitors wear protective equipment.
C. Dedicate all patient care equipment to that patient.
D. Disinfect shared equipment before use.

Correct answer: C

Rationale: When managing a patient with contact precautions, it is essential to dedicate all patient care equipment to that specific patient. This practice helps minimize the risk of spreading infections to other patients. Choice A, wearing protective gear for all patient interactions, is a general precaution but not specific to managing a patient with contact precautions. Choice B, ensuring visitors wear protective equipment, is important for infection control but not directly related to managing the patient with contact precautions. Choice D, disinfecting shared equipment before use, is a good practice for infection control in general but does not address the specific needs of a patient under contact precautions.

5. What is the most appropriate action for handling hazardous drugs?

A. Wear gloves and wash hands after handling.
B. Store the drugs according to manufacturer instructions.
C. Discard unused drugs in regular trash.
D. Wear personal protective equipment (PPE) when handling hazardous drugs.

Correct answer: D

Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.