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, shortness of breath, and a respiratory rate of 24/min.
Which of the following actions should the nurse take?
Instruct the client to cough every 4 hr.
Encourage the client to ambulate to loosen secretions.
Increase the client's intake of oral fluids.
Maintain the client in high-Fowler's position.
The Correct Answer is D
Explanation
D. Maintain the client in high-Flower’s position
Crackles in the bases of the lungs, shortness of breath, and an increased respiratory rate are signs of pulmonary congestion, which is commonly seen in heart failure. Maintaining the client in a high-Fowler's position, with the head of the bed elevated to a 45-60-degree angle, helps reduce venous return to the heart, decreases fluid accumulation in the lungs, and improves breathing comfort for the client.
The other options are not appropriate actions for the client's condition:
Instructing the client to cough every 4 hours in (option A) is not the priority action in this situation. Coughing may not effectively address the underlying cause of pulmonary congestion and may not provide immediate relief for the client.
Encouraging the client to ambulate to loosen secretions in (option B) is not the priority action in this situation. While ambulation can be beneficial for overall health, the client's symptoms of pulmonary congestion require immediate attention to improve respiratory status.
Increasing the client's intake of oral fluids in (option C) is not the priority action in this situation. While maintaining adequate hydration is important, excessive fluid intake can worsen the symptoms of heart failure and contribute to further fluid accumulation in the lungs.
Therefore, the nurse should maintain the client in high-Fowler's position (option D) to promote optimal lung function and improve breathing comfort. It is important to promptly notify the healthcare provider of the client's condition for further assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diminished pulses in the affected extremity can indicate compromised circulation, which is a serious concern. It could suggest the development of compartment syndrome, a condition characterized by increased pressure within the muscles and tissues of the leg. Compartment syndrome can lead to tissue damage and potentially jeopardize the client's limb. Therefore, it is crucial for the nurse to recognize and address this finding promptly.
One fingerbreadth of space between the cast and the skin is generally considered an appropriate amount of space to allow for swelling and adequate circulation. However, it should still be monitored for any changes or signs of compartment syndrome.
Ecchymosis on the inner left thigh may indicate bruising, which could be related to the injury or the application of the cast. While it should be documented and monitored, it does not pose an immediate threat to the client's well-being.
Client report of muscle spasms of the left leg can be a common occurrence due to muscle immobility and discomfort associated with the cast. Although it should be assessed and managed for the client's comfort, it is not as urgent as addressing compromised circulation
Correct Answer is C
Explanation
Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.
Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.
Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.
Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.
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