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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Related Questions
Correct Answer is A
Explanation
Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. When providing discharge teaching to the caregiver of a client with dependent personality disorder, it is important to promote the client's independence and self-empowerment. Encouraging the client to be assertive is an appropriate instruction because it promotes the development of self-advocacy skills and assertiveness, which can help the client gain confidence and reduce dependency on others.
limiting the client's social interactions in (option B) is incorrect because it, would not be an appropriate instruction. Restricting social interactions may further reinforce the client's dependency and hinder their ability to develop social skills and relationships.
maintaining a verbal no-harm contract with the client in (option C) is incorrect because it, is not specifically related to the management of dependent personality disorder. No-harm contracts are more commonly used in the context of managing self-harm or suicidal ideation, which may or may not be present in individuals with dependent personality disorder.
assuming responsibility for making the client's decisions in (option D) is incorrect because it, would further enable the client's dependency and undermine their autonomy. It is important to encourage the client to make their own decisions and take responsibility for their actions, within their capabilities.
Correct Answer is C
Explanation
This response demonstrates a therapeutic and non-judgmental approach, allowing the client to express their concerns, fears, or reasons for refusing to learn how to self-administer insulin. It promotes open communication and understanding between the nurse and the client, providing an opportunity to address any misconceptions, fears, or barriers the client may have. By actively listening to the client's perspective, the nurse can better tailor the education and support provided, ultimately helping the client make informed decisions regarding their healthcare.
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