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 D
Explanation
Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.
Correct Answer is A
Explanation
Choice A rationale
Sexual activity uses about as much energy as climbing two flights of stairs. This comparison can help patients understand that if they can perform activities of similar exertion without chest pain or undue fatigue, it may be safe to resume sexual activity. However, patients should always consult with their healthcare provider before resuming sexual activity after an acute myocardial infarction (AMI).
Choice B rationale
While holding and cuddling are good ways to maintain intimacy after a heart attack, this does not directly address the patient’s question about safely resuming sexual intercourse.
Choice C rationale
While it is true that the doctor will provide sexual guidelines when the patient’s heart is strong enough, this response does not provide the patient with immediate guidance or reassurance.
Choice D rationale
While most patients are able to enjoy intercourse without any complications, this statement may be too general and does not take into account the individual patient’s health status and recovery progress.
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