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.
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Naxlex Comprehensive Predictor Exams
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Explanation
It is important to use clear and concise language that is easily understandable by a wide range of readers. Writing at an 8th-grade reading level ensures that the information is accessible to a broader audience, including individuals with lower literacy levels.
Medical terminology can be confusing and overwhelming for individuals who are not familiar with healthcare terminology. Using simple and commonly understood words helps to enhance comprehension and ensures that the information is accessible to a broader audience.
Using an appropriate font size, such as 12-point, ensures that the text is legible and easy to read. Smaller font sizes can strain the eyes and make it difficult for individuals with visual impairments or reading difficulties to access the information.
It is generally more effective to present information in a logical and organized manner, starting with the foundational concepts and gradually building up to more complex information. This allows readers to grasp the basic concepts before delving into more intricate details.
By implementing these actions, the nurse can create a brochure that is informative, accessible, and easily understood by the target audience, promoting better understanding and engagement with the information provided about hypertension.
Correct Answer is A
Explanation
Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.
Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.
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