Page 1756 - Saunders Comprehensive Review For NCLEX-RN

failure indicate pulmonary edema, a life-threatening event. In pulmonary edema, the
left ventricle fails to eject sufficient blood, and pressure increases in the lungs
because of the accumulated blood. Oxygen is always prescribed, and the client is
placed in a high-Fowler’s position to ease the work of breathing. Furosemide, a
rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted
to measure output accurately. Intravenously administered morphine sulfate reduces
venous return (preload), decreases anxiety, and also reduces the work of breathing.
Transporting the client to the coronary care unit is not a priority intervention. In fact,
this may not be necessary at all if the client’s response to treatment is successful.
Test-Taking Strategy: Note the strategic word, priority, and focus on the client’s
diagnosis. Recall the pathophysiology associated with pulmonary edema and use the
ABCs—airway, breathing, and circulation—to help determine priority
interventions.
Level of Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Cardiovascular: Heart Failure
Priority Concepts: Gas Exchange; Perfusion
Reference: Ignatavicius, Workman (2016), pp. 688-689.

604. Answer: 2

Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea,
air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the
lungs reveals crackles. Rhonchi and diminished breath sounds are not associated
with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or
edema of the upper airway.
Test-Taking Strategy: Focus on the subject, breath sounds characteristic of
pulmonary edema. Recalling that fluid produces sounds that are called crackles will
assist you in eliminating the incorrect options.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Cardiovascular: Myocardial Infarction
Priority Concepts: Gas Exchange; Perfusion
Reference: Ignatavicius, Workman (2016), p. 699.

605. Answer: 2

Rationale: Dysrhythmias commonly occur as a result of decreased oxygenation
and severe damage to greater than 40% of the myocardium. Classic signs of
cardiogenic shock as they relate to myocardial ischemia include low blood pressure
and tachycardia. The central venous pressure would rise as the backward effects of
the severe left ventricular failure became apparent. Pulsus paradoxus is a finding
associated with cardiac tamponade.

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