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
a. Assign the client to a negative pressure airflow room:Varicella zoster (chickenpox or shingles) is an airborne disease, so the client should be placed in a negative pressure airflow room to prevent the spread of the virus through airborne particles.
b. Administer aspirin if the client develops a fever:Aspirin should not be administered to children or adolescents with viral infections like varicella zoster due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage.
c. Initiate contact precautions for the client: While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.
d. Have visitors remain at least 0.91 m (3 feet) away from the client:While maintaining distance can reduce the spread of many infections, varicella zoster requires more stringent precautions (airborne and contact). Instead of simply keeping a distance, visitors should be limited, and those who are not immune to varicella should avoid contact entirely.
Correct Answer is ["intramuscular injection technique"]
Explanation
The Td vaccine is typically administered into the muscle, most commonly in the deltoid muscle of the upper arm for adults. The IM injection technique involves inserting the needle into the muscle and injecting the vaccine into the muscle tissue.
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