A client in the emergency department is being cared for by a nurse and has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. What is the nurse's priority intervention?

Correct Answer: A

Rationale: The correct answer is A: Provide the client with supplemental oxygen at 5 L/min via facemask. In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation. Supplemental oxygen helps increase oxygen levels and alleviate respiratory distress, reducing the workload on the heart. This intervention addresses the client's dyspnea and anxiousness by improving oxygen delivery. Choice B is incorrect as placing the client in high-Fowler's position with legs in a dependent position can help with breathing but does not address the immediate need for oxygenation. Choice C is incorrect as sublingual nitroglycerin is typically used for angina and not the priority intervention for cardiogenic pulmonary edema. Choice D is incorrect as morphine sulfate IV may be indicated for pain relief and anxiety, but it is not the priority intervention to address the client's oxygenation needs in cardiogenic pulmonary edema.

Correct Answer: D

Rationale: The correct answer is D: Confusion. Confusion in an older adult with community-acquired pneumonia can indicate hypoxia or sepsis affecting the brain. It is a common manifestation in elderly patients with pneumonia due to impaired gas exchange and systemic inflammatory response. Unequal pupils do not typically relate to pneumonia. Hypertension is not a common finding in pneumonia; hypotension is more likely. Tympany upon chest percussion is associated with conditions like pneumothorax, not pneumonia. Therefore, confusion is the most relevant finding in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications. Step-by-step rationale: 1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage. 2. It is essential to allow the airway to recover and prevent irritation or inflammation. 3. Resting the voice can aid in the healing process and reduce the risk of complications. 4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest. 5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications. 6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.

Correct Answer: B

Rationale: The correct answer is B: 480 mL. For a client with an ideal weight of 60 kg, the tidal volume should be set at 6-8 mL/kg of ideal body weight. Therefore, for a 60 kg individual, the tidal volume should be between 360-480 mL. B falls within this range and is the most appropriate choice. A: 300 mL is too low and would not provide adequate ventilation for a client of this weight. C: 800 mL is too high and could lead to overventilation and potential lung injury. D: 950 mL is also too high and poses the same risks as option C. In summary, B is the correct choice as it falls within the appropriate tidal volume range based on the client's ideal weight, while the other options are either too low or too high.

Correct Answer: B

Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.