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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
After a laparoscopic cholecystectomy, steri-strips or adhesive strips are commonly placed over the small incisions. The client should keep the steri-strips in place until they fall off on their own or until they are removed by the healthcare provider during a follow-up visit. Removing the steri-strips prematurely can increase the risk of infection or disrupt the healing process.
"I should eat a high-fat diet for several weeks": After a laparoscopic cholecystectomy, it is important for the client to follow a low-fat diet initially to allow the body time to adjust to the absence of the gallbladder. High-fat foods can be more difficult to digest and may cause digestive discomfort. Gradually introducing small amounts of fat back into the diet is recommended, but a high-fat diet is not appropriate.
"I should expect to have diarrhea until my diet changes": While changes in bowel movements can occur after a cholecystectomy, such as looser stools or changes in frequency, persistent diarrhea is not expected or normal. If the client experiences persistent diarrhea, they should contact their healthcare provider for further evaluation.
"I should expect to have nausea for several days": While some clients may experience mild nausea or discomfort after the surgery, it should generally improve within a few days. If the client experiences persistent or severe nausea, they should contact their healthcare provider.
Correct Answer is B
Explanation
Incident report
In the given scenario, where the nurse inadvertently administers 2 tablets of acetaminophen with codeine instead of the prescribed dose of 1 tablet, the nurse should document this client care incident in an incident report.
An incident report is a formal record that documents any unexpected or adverse events that occur during the provision of healthcare. It serves as a tool for identifying and addressing potential risks and improving patient safety. The incident report should include a detailed account of what happened, including the date, time, individuals involved, description of the incident, and any potential harm or actual harm caused to the client. It should be completed as soon as possible after the incident occurs.
Provider's progress notes in (option A) is incorrect: Provider's progress notes are used to document the healthcare provider's assessment, diagnosis, treatment plan, and progress of the client's condition. It is not the appropriate place to document a client care incident like an administration error.
Controlled substance inventory record in (option C) is incorrect: The controlled substance inventory record is used to track the use and documentation of controlled substances in a healthcare facility. While medication errors involving controlled substances should be reported and documented, the controlled substance inventory record is not the appropriate place for documenting a client care incident.
Nursing care plan in (option D) is incorrect: The nursing care plan outlines the client's nursing diagnoses, goals, and nursing interventions. It is not the appropriate place to document a client care incident like a medication administration error.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today