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 C
Explanation
Giving change -of-shift report to a nurse outside the client’s room
Protecting client confidentiality is an essential aspect of providing healthcare. Confidentiality ensures that sensitive client information remains private and is not disclosed to unauthorized individuals.
Giving change-of-shift report to a nurse outside the client's room: This is an appropriate action as long as the nurse ensures that the conversation occurs in a private and secure location where unauthorized individuals cannot overhear the discussion. This protects the client's confidentiality while allowing for effective communication and continuity of care.
Discarding worksheets containing client information in a wastebasket in (option A) is not an appropriate action, as discarding worksheets containing client information in a wastebasket can expose the information to unauthorized individuals. Instead, the nurse should follow proper procedures for the disposal of confidential information, such as shredding or using secure disposal methods.
Writing a client's diagnosis on the message board in the client's room in (option B) is not an appropriate action, as it can compromise the client's privacy. The nurse should avoid posting or displaying any client- specific information in public areas where it can be accessed by unauthorized individuals. Confidential information should be shared only on a need-to-know basis with healthcare professionals involved in the client's care.
Discussing a client's prognosis with assistive personnel who is caring for the client in (option D) is not an appropriate action, as discussing a client's prognosis with unauthorized individuals breaches the client's confidentiality. Prognosis and sensitive medical information should be discussed only among healthcare professionals directly involved in the client's care and on a need-to-know basis.
Correct Answer is A
Explanation
A. Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider. Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling on the tube, which can be uncomfortable for the child and may cause complications. This action helps maintain the position of the tube and prevents tension or pulling on the insertion site.
B.Attaching an extension tube allows for easier access to the enteral feeding or medication administration port without needing to manipulate the primary tubing frequently. This action facilitates feeding or medication administration and minimizes the risk of contamination or damage to the primary tubing.Attaching an extension tube is done for feeding purposes, not during site care.
Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
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