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 B
Explanation
Correct answer: B
a. Lowering the side rails is unnecessary and could increase the risk of falling. The side rails should be raised and padded instead.
b.The nurse should observe and document the duration of the seizure. This information helps in assessing the severity and guiding further interventions
c.Restraining the client's arms and legs to prevent injury is not recommended during a seizure. Restraining a person during a seizure can increase the risk of injury and may impede their ability to move or protect themselves during the seizure.
d.Inserting an oral airway into the client's mouth is not indicated during a tonic-clonic seizure. It is generally not recommended to place any objects or devices into the mouth of a person having a seizure, as it can potentially cause injury to the person or damage to the airway
Correct Answer is D
Explanation
After a laparoscopic cholecystectomy, steri-strips or adhesive strips are commonly placed over the small incisions. The client should keep the steri-strips in place until they fall off on their own or until they are removed by the healthcare provider during a follow-up visit. Removing the steri-strips prematurely can increase the risk of infection or disrupt the healing process.
"I should eat a high-fat diet for several weeks": After a laparoscopic cholecystectomy, it is important for the client to follow a low-fat diet initially to allow the body time to adjust to the absence of the gallbladder. High-fat foods can be more difficult to digest and may cause digestive discomfort. Gradually introducing small amounts of fat back into the diet is recommended, but a high-fat diet is not appropriate.
"I should expect to have diarrhea until my diet changes": While changes in bowel movements can occur after a cholecystectomy, such as looser stools or changes in frequency, persistent diarrhea is not expected or normal. If the client experiences persistent diarrhea, they should contact their healthcare provider for further evaluation.
"I should expect to have nausea for several days": While some clients may experience mild nausea or discomfort after the surgery, it should generally improve within a few days. If the client experiences persistent or severe nausea, they should contact their healthcare provider.
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