The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is:

Correct Answer: B

Rationale: In the case of a client with congestive heart failure and pulmonary edema, the primary nursing diagnosis would be impaired gas exchange (Option B). This is because in pulmonary edema, there is an accumulation of fluid in the lungs, which impairs the exchange of oxygen and carbon dioxide across the alveolar-capillary membrane. This can lead to hypoxemia and respiratory distress, making impaired gas exchange a priority. Option A, pain, is not the most appropriate nursing diagnosis for this scenario because while the client may experience discomfort, the priority is addressing the respiratory distress and impaired gas exchange. Option C, decreased cardiac output, is a common complication of congestive heart failure but is not the primary concern in a client presenting with pulmonary edema. Option D, fluid volume excess, is related to the pathophysiology of congestive heart failure but is not the primary nursing diagnosis in this case. While fluid volume excess may contribute to pulmonary edema, the immediate focus should be on improving gas exchange to ensure adequate oxygenation. Educationally, understanding the rationale behind choosing impaired gas exchange as the primary nursing diagnosis reinforces the importance of prioritizing patient needs based on the presenting symptoms and pathophysiology. It highlights the critical thinking skills required in nursing to differentiate between various symptoms and select the most urgent issue to address for the client's well-being.

Correct Answer: A

Rationale: Prevention of infection, and potential septicemia, is of prime importance for someone with a central catheter. Mixing TPN is a very specialized procedure, and should be done under laminar airflow by a pharmacist. IV pumps are machines that do malfunction, but the safest thing to do would be to get the manufacturer to do the repair. Having neighbors be a support to Chelsea and her family may not be possible. More information would be necessary prior to choosing this as an option for a nursing diagnosis.

Correct Answer: A

Rationale: Adequate air exchange and tissue oxygenation depends upon competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but is secondary to airway management. Re-orienting a client to time, place, and person and knowing that their surgery is over is important, but is secondary to airway management and taking vital signs. Airway management takes precedence over the physician's orders, unless the orders specifically relate to airway management.

Correct Answer: D

Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.

Correct Answer: B

Rationale: The correct answer is B: urinary incontinence is usually temporary. This response is accurate because after the removal of a Foley catheter following a TURP procedure, it is common for patients to experience temporary urinary incontinence due to the bladder needing time to regain its normal function. This explanation reassures the client that his current experience is a normal part of the recovery process and is likely to improve over time with proper management and support. Option A: he should not be concerned, because it will be quickly resolved. This option is incorrect because it may provide false reassurance and not address the client's concerns adequately. It is essential to acknowledge the client's worries and provide accurate information to empower him during his recovery. Option C: he should notify the nurse when this happens. While it is important for the client to communicate any changes or concerns with the healthcare team, this option does not provide the client with the necessary information about the expected course of urinary incontinence post-Foley catheter removal. Option D: this is related to the bladder spasms and will soon stop. This option is incorrect as it provides a specific cause for the incontinence without acknowledging the broader context of post-TURP recovery, which involves multiple factors contributing to urinary symptoms beyond just bladder spasms. In an educational context, it is crucial for nurses to provide accurate and comprehensive information to patients regarding common postoperative experiences like urinary incontinence. By explaining the temporary nature of this symptom, nurses can help alleviate patient anxiety, promote understanding of the recovery process, and enhance overall patient satisfaction and compliance with care plans.