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 B
Explanation
Choice A rationale:
Uncapped sharps being put in a puncture-resistant container (choice A) is a safe and appropriate practice for the disposal of sharp objects, such as needles. This choice demonstrates adherence to infection control principles and minimizes the risk of accidental needlestick injuries.
Choice B rationale:
Soiled linens being placed on the floor (choice B) is not a safe or acceptable practice. Placing soiled linens on the floor can lead to contamination of the environment and pose a risk of spreading infection. Proper linen disposal protocols should be followed, which may include using designated linen hampers or containers.
Choice C rationale:
Waste containers being lined with single bags (choice C) is a standard practice for waste disposal. Using single bags makes it easier to handle and dispose of waste materials safely. It is a recommended infection control measure.
Choice D rationale:
Dampened cloths being used for dusting the area (choice D) is generally a safe practice for cleaning and dusting surfaces. Dampened cloths can help prevent the spread of dust and allergens. However, it's essential to ensure that the cloths are cleaned and disinfected regularly to prevent bacterial growth.
Correct Answer is D
Explanation
Choice A rationale:
Delaying the discussion about managing hair loss when the client has expressed concern is not the best approach. The nurse should provide information and support when the client seeks it.
Choice B rationale:
Discouraging the client from worrying about hair loss at this moment is not empathetic. The client's concerns should be acknowledged and addressed.
Choice C rationale:
Expressing empathy and relating to the client's emotional experience is a good practice, but it does not directly answer the client's question about managing hair loss.
Choice D rationale:
Offering to get information about head-covering options indicates an understanding of the client's concerns and provides a proactive solution. It shows empathy and willingness to support the client during chemotherapy, where hair loss can be a significant emotional issue.
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