A nurse is caring for a client who has dementia.

Which of the following findings should the nurse expect?

Choice A Reason:

Maintaining the client in high-Fowler's position is a correct action. Keeping the client in a high-Fowler's position (sitting up with the head of the bed elevated) can help improve lung expansion and ease breathing for clients with heart failure and respiratory distress.

Choice B Reason:

Instructing the client to cough every 4 hr. is not directly addressing the underlying issue of fluid accumulation and respiratory distress associated with heart failure. Coughing alone may not be sufficient to alleviate these symptoms.

Choice C Reason:

Increasing the client's intake of oral fluids is generally not recommended without considering the client's overall fluid status. In heart failure, there is often a need to restrict fluid intake to prevent fluid overload and worsening of symptoms. Increasing oral fluids should be done cautiously and under the guidance of the healthcare provider.

Choice D Reason:

Encouraging the client to ambulate to loosen secretions. While ambulation can be beneficial for some clients to improve overall circulation and prevent complications, it may not be the primary intervention in this case. The client's primary issue is likely related to pulmonary congestion due to heart failure, and they may be too short of breath to ambulate effectively.

Choice A Reason:

The shortness of breath is correct. Albuterol is a bronchodilator medication commonly used to relieve symptoms of shortness of breath and wheezing in individuals with conditions such as asthma or chronic obstructive pulmonary disease (COPD). It helps to relax the muscles in the airways, allowing for easier breathing. It is not used to treat swelling of the lips, nausea, or hyperglycemia.

The other choices are not the answer because albuterol is specifically indicated for the treatment of respiratory symptoms like shortness of breath and wheezing associated with conditions like asthma or COPD. Here's why the other options are not correct:

Choice B Reason:

Swelling of the lips is incorrect. Albuterol is not used to treat lip swelling. Lip swelling may be related to allergies or other medical conditions, and treatment would depend on the underlying cause.

Choice C Reason:

Nausea is incorrect. Albuterol is not used to treat nausea. Nausea can have various causes, and treatment would depend on the underlying reason for the nausea.

Choice D Reason:

Hyperglycemia is incorrect. Albuterol does not treat hyperglycemia (high blood sugar). It is used for respiratory symptoms, not for managing blood sugar levels. Treatment for hyperglycemia typically involves medications such as insulin or oral antidiabetic agents, as well as dietary and lifestyle changes.