Correct Answer: Frothy, pink sputum
Rationale
Frothy, pink sputum is correct.
Rationale: Left-sided heart failure causes fluid backup into the pulmonary circulation,
leading to pulmonary congestion. Frothy, pink sputum indicates alveolar edema and is a
hallmark sign of acute pulmonary congestion
,Correct Answer: Document the client's refusal in the medical record.
Rationale The nurse must respect a competent client's right to refuse treatment and is legally
required to document this refusal and the associated education provided in the permanent
medical record.
,Correct Answer: Complete activities for one client before moving to the next client.
Rationale
Finishing tasks for one client before starting another prevents fragmentation of care and reduces
the risk of errors associated with multitasking and frequent interruptions.
, Correct Answer: Measure the arm circumference above the insertion site daily.
Rationale
Daily measurement of the arm circumference is essential to monitor for complications such as
thrombosis, lymphedema, or infiltration associated with a PICC line.
Rationale
Frothy, pink sputum is correct.
Rationale: Left-sided heart failure causes fluid backup into the pulmonary circulation,
leading to pulmonary congestion. Frothy, pink sputum indicates alveolar edema and is a
hallmark sign of acute pulmonary congestion
,Correct Answer: Document the client's refusal in the medical record.
Rationale The nurse must respect a competent client's right to refuse treatment and is legally
required to document this refusal and the associated education provided in the permanent
medical record.
,Correct Answer: Complete activities for one client before moving to the next client.
Rationale
Finishing tasks for one client before starting another prevents fragmentation of care and reduces
the risk of errors associated with multitasking and frequent interruptions.
, Correct Answer: Measure the arm circumference above the insertion site daily.
Rationale
Daily measurement of the arm circumference is essential to monitor for complications such as
thrombosis, lymphedema, or infiltration associated with a PICC line.
