A nurse is caring for a client with a history of left-sided heart failure who begins to experience dyspnea and reports that “it feels hard to catch my breath.” The nurse notes increased respiratory effort and auscultates crackles in the bilateral lung bases. Which initial nursing intervention is most appropriate?
Reinforce teaching of using the incentive spirometer hourly
Encourage the client to cough and deep breathe
Elevate the head of the bed 45 degrees
Place the client in high Fowler’s position
The Correct Answer is D
Choice A reason: Incentive spirometry improves lung expansion but is not the priority in acute heart failure with pulmonary edema. Crackles and dyspnea indicate fluid overload, requiring immediate positioning to reduce respiratory distress, making this intervention less urgent than optimizing breathing mechanics.
Choice B reason: Coughing and deep breathing may help clear airways but do not address the underlying pulmonary edema in left-sided heart failure. Fluid in the alveoli causes crackles and dyspnea, requiring positioning to reduce venous return and improve oxygenation, making this less effective initially.
Choice C reason: Elevating the head of the bed to 45 degrees can reduce venous return and ease breathing in heart failure. However, high Fowler’s position (60–90 degrees) is more effective for severe dyspnea and pulmonary edema, as it maximizes lung expansion and oxygenation.
Choice D reason: High Fowler’s position (60–90 degrees) reduces venous return to the heart, decreasing pulmonary congestion in left-sided heart failure. This alleviates dyspnea and crackles by improving lung expansion and oxygenation, making it the most effective initial intervention for acute respiratory distress in this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Impotence is a potential side effect of SSRIs due to serotonin’s effect on sexual function but is not a symptom of serotonin syndrome, a life-threatening condition involving excessive serotonin causing hyperthermia, agitation, and muscle rigidity, making this incorrect.
Choice B reason: Hypotension is not a primary symptom of serotonin syndrome, which involves serotonin excess leading to hyperthermia, tremors, and autonomic instability. Hypotension may occur secondary to severe cases but is not a hallmark symptom included in teaching.
Choice C reason: Fever is a key symptom of serotonin syndrome, caused by excessive serotonin stimulation leading to hyperthermia, muscle rigidity, and autonomic dysfunction. It’s a critical teaching point, as it signals a medical emergency requiring immediate intervention to prevent organ damage.
Choice D reason: Constipation is a side effect of some SSRIs due to serotonin’s effect on gastrointestinal motility but is not associated with serotonin syndrome. This condition involves acute neurological and autonomic symptoms, not chronic gastrointestinal issues, making this incorrect.
Correct Answer is A
Explanation
Choice A reason: A ventricular pacemaker stimulates the ventricles, producing a spike on the ECG before each QRS complex, indicating proper pacing and capture. This ensures the ventricles contract in response to the pacemaker’s electrical impulse, maintaining adequate cardiac output in clients with conduction issues.
Choice B reason: Pacemaker spikes after each P wave suggest atrial pacing, not ventricular pacing. Ventricular pacemakers target ventricular contraction, so spikes should precede the QRS complex, not follow the P wave, making this an incorrect indicator of proper ventricular pacemaker function.
Choice C reason: Pacemaker spikes with each T wave are not indicative of proper ventricular pacemaker function. T waves represent ventricular repolarization, and pacing at this phase is ineffective and potentially dangerous, as it does not initiate ventricular contraction, ruling out this option.
Choice D reason: Pacemaker spikes after each QRS complex indicate failure to pace appropriately, as ventricular depolarization has already occurred. Proper ventricular pacing requires spikes before the QRS to initiate contraction, making this an incorrect sign of a functioning ventricular pacemaker.
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