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?
Increase the client's intake of oral fluids.
Instruct the client to cough every 4 hr.
Maintain the client in high-Fowler's position.
Encourage the client to ambulate to loosen secretions.
The Correct Answer is C
Choice A rationale:
Increasing the client's intake of oral fluids may not address the underlying issue of crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. This client likely has fluid accumulation in the lungs, and simply increasing fluid intake could exacerbate the problem. It's important to assess and manage the client's fluid balance carefully.
Choice B rationale:
Instructing the client to cough every 4 hours may not be sufficient for managing the client's symptoms, especially if there is fluid in the lungs. Coughing alone may not adequately clear the airways. More intensive interventions are needed.
Choice C rationale:
The correct action is to "Maintain the client in high-Fowler's position." High-Fowler's position helps improve lung expansion and oxygenation by allowing the client to sit up at an angle, which reduces pressure on the diaphragm and improves lung mechanics. This position can help alleviate symptoms such as crackles and shortness of breath in clients with heart failure.
Choice D rationale:
Encouraging the client to ambulate to loosen secretions may not be appropriate in this case. Ambulation is generally encouraged for clients with adequate oxygenation and mobility. If the client has severe respiratory distress, it's crucial to address that issue first before considering ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The nurse should not recommend placing the diaper over the strap of the Pavlik harness. Placing the diaper over the strap can cause discomfort and may interfere with the proper function of the harness, which is designed to maintain hip joint alignment in infants with developmental hip dysplasia.
Choice B rationale:
The Pavlik harness is typically worn continuously, including during sleep. It should not be removed for sleeping each night because consistent use is essential for its effectiveness in promoting hip joint development.
Choice C rationale:
Applying lotion under the straps of the harness is not recommended. Lotions or creams can create friction and moisture, which may lead to skin irritation or discomfort for the infant. It's best to follow the healthcare provider's instructions regarding the care and maintenance of the harness.
Choice D rationale:
The correct choice is D. The nurse should include the statement that "The harness can promote hip joint development" in the teaching. This is because the Pavlik harness is used to treat developmental hip dysplasia by maintaining the hip joint in a stable position, allowing for proper development. It is important for parents to understand the purpose and benefits of the harness in order to ensure compliance and effectiveness of the treatment.
Correct Answer is A
Explanation
Choice A rationale:
Supplement spoken language with pictures. Rationale: When caring for a client who speaks a different language, supplementing spoken language with pictures or visual aids is a helpful communication strategy. Visual aids can assist in conveying important information, instructions, and concepts effectively, especially when there is a language barrier.
Choice B rationale:
Ask a family member of the client to interpret. Rationale: Relying on a family member to interpret can be problematic, as it may compromise the privacy and confidentiality of the client's healthcare information. Additionally, family members may not always be available or proficient in the required language, making it an unreliable method of communication.
Choice C rationale:
Recognize that the client nodding indicates an understanding of the information. Rationale: Assuming that nodding indicates understanding is not a reliable approach, as nodding can have different cultural interpretations and may not necessarily indicate comprehension. It is important to use clear and simple language, along with visual aids when necessary, to ensure effective communication.
Choice D rationale:
Speak to the client at an increased volume. Rationale: Speaking at an increased volume is not an appropriate approach to communication with a client who speaks a different language. It can be perceived as rude or aggressive and is unlikely to improve understanding. Clear and concise communication, along with visual aids or interpretation services when needed, is a more effective strategy.
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