A client exhibits tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum. What position should the nurse place the client in?
Trendelenburg position.
Sims’ position.
Semi-Fowler’s position.
Fowler’s position with legs lowered.
The Correct Answer is D
The symptoms described - tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum - are indicative of acute pulmonary edema, a condition characterized by fluid accumulation in the lungs due to heart failure. In this situation, the Fowler’s position (sitting up at a 45-60 degree angle) with legs lowered is recommended. This position helps to reduce venous return to the heart, thereby decreasing the workload on the heart and helping to alleviate symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The apical pulse, also known as the point of maximal impulse (PMI), is located at the fifth intercostal space at the left midclavicular line. This is the location where the heartbeat is strongest and is the standard location for assessing the apical heart rate.
Choice B rationale
Placing the stethoscope directly over the heart on the sternum is not the standard method for assessing the apical heart rate. While the sternum is close to the heart, it is not the location where the heartbeat is strongest or most easily heard.
Choice C rationale
The right side at the midclavicular line, fourth intercostal space, is not the standard location for assessing the apical heart rate. The heart is located more towards the left side of the chest, and the apical pulse is typically not as easily heard on the right side.
Choice D rationale
The midaxillary line on the left side is not the standard location for assessing the apical heart rate. While this location is on the left side of the chest, it is not where the heartbeat is strongest or most easily heard.
Correct Answer is D
Explanation
The symptoms described - tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum - are indicative of acute pulmonary edema, a condition characterized by fluid accumulation in the lungs due to heart failure. In this situation, the Fowler’s position (sitting up at a 45-60 degree angle) with legs lowered is recommended. This position helps to reduce venous return to the heart, thereby decreasing the workload on the heart and helping to alleviate symptoms.
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