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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A .Lie on your left side with your top leg forward

During pregnancy, it is generally recommended for pregnant individuals to sleep on their left side. This position promotes optimal blood flow and circulation to the uterus and placenta, which is beneficial for both the mother and the baby. Placing the top leg forward can help maintain a comfortable and supported position.

Soaking in a bathtub of hot water each night in (option B) is not recommended during pregnancy, as excessive heat from hot baths or saunas can potentially harm the developing fetus. Pregnant individuals should avoid prolonged exposure to hot temperatures.

Obtaining a prescription for pramipexole in (option C) is not a standard intervention for addressing trouble sleeping during pregnancy. Pramipexole is a medication used for the treatment of Parkinson's disease and restless legs syndrome, and its use during pregnancy should be evaluated on a case-by-case basis under the guidance of a healthcare provider.

Using a transcutaneous electrical nerve stimulator (TENS) in (option D) is not typically indicated for sleep difficulties during pregnancy. TENS units are commonly used for pain management, and their use for sleep problems during pregnancy is not a standard recommendation.

A. Provide the client with a glass of orange juice. B. Instruct the client to take a brisk walk. C. Position the client on their left side. D. Check the client's temperature.

Correct Answer is C

Explanation

Explanation

C. Position the client on their left side

The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.

Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.

Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.

Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.

Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.

Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).

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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?

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Correct Answer is A

Explanation

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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?