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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Related Questions
Correct Answer is C
No explanation
Correct Answer is C
Explanation
Overhearing a discussion about a client's private information is a breach of confidentiality, and it is the nurse's responsibility to address the situation promptly.
While documenting the event in the client's progress notes might be necessary in some cases, it is not the initial action to take in this scenario. Similarly, submitting an incident report to the risk manager may be required for documentation purposes, but it is not the immediate action to address the breach of confidentiality.
Informing the client of the APs' actions may not be necessary unless there is evidence that the client's privacy has been compromised or if the client specifically requests to know. However, the priority is to address the issue of the conversation between the APs and ensure that confidentiality is maintained.
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