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 C
Explanation
When collecting data from a child with pertussis (whooping cough), the nurse should expect the following manifestations:
- Paroxysmal cough: The hallmark symptom of pertussis is a severe, uncontrollable cough that often occurs in bursts (paroxysms) followed by a characteristic "whooping" sound as the child inhales.
- Posttussive vomiting: The coughing spells can be so severe that they may lead to vomiting.
- Inspiratory whoop: As mentioned earlier, during the inhalation phase after a coughing episode, the child may make a distinctive whooping sound.
- Cyanosis: The prolonged coughing episodes can sometimes cause the child's face to turn blue (cyanosis) due to inadequate oxygen intake.
- Fatigue and exhaustion: The frequent and intense coughing episodes can be exhausting for the child, leading to fatigue and sleep disturbances.
Other possible manifestations of pertussis can include a mild fever, runny nose, and sneezing. However, these symptoms are less specific to pertussis and can be seen in other respiratory infections as well.
The manifestations listed in the question (beefy, red tongue; facial erythema; peeling of the hands and feet) are not typically associated with pertussis and may be indicative of other conditions or diseases. It is important to consult a healthcare provider for a proper evaluation and diagnosis.
Correct Answer is A
Explanation
Explanation
A. Placement of a central venous catheter
Informed consent is a legal and ethical requirement that ensures clients have the necessary information to make autonomous decisions about their healthcare. The healthcare provider must obtain informed consent before performing any procedure that carries potential risks or benefits. Here's why the other options do not typically require informed consent:
Administration of an iron injection using Z-track technique in (option B) is not correct because, while informed consent may be required for administering certain medications or injections, the specific technique used, such as the Z-track technique, typically does not require separate informed consent. The Z-track technique is a method used to prevent leakage of the medication into subcutaneous tissues during injection.
Insertion of a nasogastric tube in (option C) is not correct because Insertion of a nasogastric tube is a common procedure performed to access the stomach or administer medications or nutrients. Informed consent is generally not required for nasogastric tube insertion as it is considered a routine procedure and is often included as part of the overall plan of care.
Irrigation of a wound with antibiotic solution in (option D) is not correct because wound irrigation is a standard procedure in wound care, and the use of an antibiotic solution may be part of the healthcare provider's prescribed treatment plan. Informed consent is typically not required for wound irrigation unless there are specific circumstances or risks associated with the procedure.
In summary, the nurse should identify that informed consent is required for A: Placement of a central venous catheter. This procedure involves the insertion of a catheter into a major blood vessel and carries potential risks and complications that require informed consent to ensure the client's understanding and agreement before proceeding
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