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 A
Explanation
Stressors can be categorized as external or internal. External stressors are factors or events in the environment that can cause stress.
In this case, the recent move to a new city is an external stressor because it is an event that has occurred outside of the client and is influencing their current state of stress. Moving to a new city can bring about significant changes and challenges, such as adjusting to a new environment, finding new social connections, and adapting to unfamiliar surroundings.
Feeling depressed is an internal stressor because it relates to the client's emotional state or mental health condition. Depression can be caused by various factors, such as biochemical imbalances, life circumstances, or genetic predispositions.
Lack of nutritional knowledge: This is an internal stressor because it refers to the client's lack of knowledge or awareness regarding nutrition. While the lack of nutritional knowledge can contribute to stress, it is an internal factor that can be addressed through education and learning.
While recurring urinary tract infections can be stressful for the client, they are considered an internal stressor because they involve a physical condition or health issue within the client's body. Addressing and managing the infections would involve medical interventions and possibly lifestyle modifications.
Correct Answer is B
Explanation
Bran muffins are a good choice for relieving constipation because they are high in dietary fiber. Fiber adds bulk to the stool and helps promote regular bowel movements. It can soften the stool, making it easier to pass.
Puffed rice cereal is a low-fiber food and may not provide significant relief for constipation. It is typically low in fiber and may not help in promoting regular bowel movements.
Tomato juice, while a healthy choice, is not particularly high in fiber. It contains some fiber, but not as much as other options like bran muffins.
Cottage cheese is a good source of protein, but it is not known for its high fiber content. While it can be a part of a balanced diet, it may not have a significant impact on relieving constipation.
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