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 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.
Encourage the client to ambulate to loosen secretions.
Maintain the client in high-Fowler's position.
The Correct Answer is D
The client's crackles in the bases of the lungs and an increased respiratory rate indicate the presence of fluid accumulation in the lungs, which is commonly seen in clients with heart failure. Maintaining the client in a high Fowler's position helps to promote optimal lung expansion and ventilation by reducing the pressure on the diaphragm, allowing for improved breathing mechanics and enhanced oxygenation.
Increasing the client's intake of oral fluids: While maintaining hydration is generally important, increasing oral fluids may not directly address the issue of fluid accumulation in the lungs. The priority in this situation is to optimize the client's respiratory function.
Instructing the client to cough every 4 hours: Coughing alone may not be sufficient to resolve the fluid accumulation. The underlying cause of the crackles and increased respiratory rate in heart failure is fluid congestion, which requires more comprehensive management.
Encouraging the client to ambulate to loosen secretions: While ambulation is generally beneficial for clients with heart failure, it may not directly address the fluid accumulation in the lungs. Ambulation can help improve overall cardiovascular function and fluid balance, but in the presence of acute respiratory distress or significant fluid overload, the client may not be able to tolerate or benefit from ambulation immediately.
In addition to maintaining the client in a high-Fowler's position, the nurse should also collaborate with the healthcare provider to initiate appropriate interventions, such as administering diuretic medications to help remove excess fluid and improve respiratory status. Monitoring the client's oxygen saturation, providing supplemental oxygen as needed, and assessing other vital signs are also important aspects of care in managing heart failure-related respiratory symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Reduced fat in the stools
Pancrelipase is an enzyme replacement therapy used in the treatment of cystic fibrosis, a condition that affects the exocrine glands, including the pancreas. Cystic fibrosis impairs the production and secretion of digestive enzymes, leading to malabsorption of nutrients, particularly fats.
Pancrelipase contains enzymes (lipase, amylase, and protease) that help in the digestion of fats, carbohydrates, and proteins, respectively. By administering pancrelipase, the nurse aims to improve the digestion and absorption of nutrients, especially fats. As a result, one of the therapeutic effects of pancrelipase in a child with cystic fibrosis is a reduction in fat in the stools, as the enzymes help break down dietary fats properly, preventing their excretion undigested.
Improved respiratory function in (option B) is not correct because while cystic fibrosis primarily affects the respiratory system, the administration of pancrelipase does not directly improve respiratory function. Other treatments and interventions are used to manage respiratory symptoms in cystic fibrosis.
Improved absorption of vitamins B and C in (option C) is not correct because Pancrelipase primarily aids in the digestion and absorption of fats, carbohydrates, and proteins. Although the absorption of vitamins can be indirectly affected by improved digestion, the main therapeutic effect of pancrelipase is related to fat digestion.
Decreased sodium excretion in (option D) is not correct because Pancrelipase does not have a direct effect on sodium excretion. Sodium balance is primarily regulated by the kidneys, and interventions targeting sodium excretion would involve dietary changes or medications targeting renal function.
Correct Answer is B
Explanation
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel toward the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.
"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.
"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.
"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.
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