A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs and a respiratory rate of 24/min. Which of the following actions should the nurse take?
Increase the client's intake of oral fluids.
Instruct the client to cough every 4 hr.
Encourage the client to ambulate to loosen secretions.
Maintain the client in high-Fowler's position.
The Correct Answer is D
The client's crackles in the bases of the lungs and an increased respiratory rate indicate the presence of fluid accumulation in the lungs, which is commonly seen in clients with heart failure. Maintaining the client in a high Fowler's position helps to promote optimal lung expansion and ventilation by reducing the pressure on the diaphragm, allowing for improved breathing mechanics and enhanced oxygenation.
Increasing the client's intake of oral fluids: While maintaining hydration is generally important, increasing oral fluids may not directly address the issue of fluid accumulation in the lungs. The priority in this situation is to optimize the client's respiratory function.
Instructing the client to cough every 4 hours: Coughing alone may not be sufficient to resolve the fluid accumulation. The underlying cause of the crackles and increased respiratory rate in heart failure is fluid congestion, which requires more comprehensive management.
Encouraging the client to ambulate to loosen secretions: While ambulation is generally beneficial for clients with heart failure, it may not directly address the fluid accumulation in the lungs. Ambulation can help improve overall cardiovascular function and fluid balance, but in the presence of acute respiratory distress or significant fluid overload, the client may not be able to tolerate or benefit from ambulation immediately.
In addition to maintaining the client in a high-Fowler's position, the nurse should also collaborate with the healthcare provider to initiate appropriate interventions, such as administering diuretic medications to help remove excess fluid and improve respiratory status. Monitoring the client's oxygen saturation, providing supplemental oxygen as needed, and assessing other vital signs are also important aspects of care in managing heart failure-related respiratory symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
No explanation
Correct Answer is B
Explanation
Turn the child on to their side
When a child is experiencing a tonic-clonic seizure, the priority is to ensure their safety and protect their airway. Turning the child onto their side helps to prevent aspiration and maintain an open airway by allowing any saliva or fluids to drain out of the mouth. This position also helps to minimize the risk of injury.
The other options are incorrect:
Restraining the child's upper extremities in (option A) is not recommended during a seizure as it can potentially cause harm to the child or others around them.
Placing a padded tongue blade in the child's mouth in (option C) is an outdated practice that is no longer recommended. It can cause injury and is not necessary during a seizure.
Placing a pillow under the child's head in (option D) is generally not recommended during a seizure. It can interfere with the positioning of the head and may compromise the airway. The focus should be on maintaining an open airway and preventing injury, which is achieved by turning the child onto their side.
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