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, shortness of breath, and a respiratory rate of 24/min.
Which of the following actions should the nurse take?
Instruct the client to cough every 4 hr.
Encourage the client to ambulate to loosen secretions.
Increase the client's intake of oral fluids.
Maintain the client in high-Fowler's position.
The Correct Answer is D
Explanation
D. Maintain the client in high-Flower’s position
Crackles in the bases of the lungs, shortness of breath, and an increased respiratory rate are signs of pulmonary congestion, which is commonly seen in heart failure. Maintaining the client in a high-Fowler's position, with the head of the bed elevated to a 45-60-degree angle, helps reduce venous return to the heart, decreases fluid accumulation in the lungs, and improves breathing comfort for the client.
The other options are not appropriate actions for the client's condition:
Instructing the client to cough every 4 hours in (option A) is not the priority action in this situation. Coughing may not effectively address the underlying cause of pulmonary congestion and may not provide immediate relief for the client.
Encouraging the client to ambulate to loosen secretions in (option B) is not the priority action in this situation. While ambulation can be beneficial for overall health, the client's symptoms of pulmonary congestion require immediate attention to improve respiratory status.
Increasing the client's intake of oral fluids in (option C) is not the priority action in this situation. While maintaining adequate hydration is important, excessive fluid intake can worsen the symptoms of heart failure and contribute to further fluid accumulation in the lungs.
Therefore, the nurse should maintain the client in high-Fowler's position (option D) to promote optimal lung function and improve breathing comfort. It is important to promptly notify the healthcare provider of the client's condition for further assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct answer: A
Preschool-aged children (around 3 to 5 years old) have a limited understanding of death compared to older children or adults. They may not fully grasp the finality and permanence of death. They often have a more concrete and literal understanding of death.
A. Believing the death is punishment for bad behavior: Preschool-aged children (typically 3 to 5 years old) often have magical thinking and may believe that their thoughts or actions can cause events to happen. They may think that the death of a parent is a punishment for something they did or thought, reflecting their egocentric view of the world.
B. Recognizing the parent will never wake up: This understanding is more commonly seen in older children who have a more mature grasp of death. Preschool-aged children may not fully comprehend that death is irreversible and permanent.
C. While preschoolers might ask questions about the funeral out of curiosity, this is not the primary way they process or react to the death of a loved one. Their questions are often more about trying to understand what is happening rather than a genuine curiosity about the specifics of the service.
D. Understanding that everyone dies eventually: While preschool-aged children may have some understanding that death is a natural part of life, their comprehension of its full implications is limited. They may not fully grasp the universality of death and its inevitability for all living beings.
Correct Answer is D
Explanation
Epinephrine is a medication commonly used to treat severe allergic reactions, also known as anaphylaxis. One of the hallmark signs of anaphylaxis is difficulty breathing or shortness of breath. Epinephrine works by constricting blood vessels, relaxing smooth muscles in the airways, and reducing swelling, which can help relieve the symptoms of respiratory distress. Epinephrine is not typically used to treat nausea, hyperglycemia, or hand tremors.
Nausea can be caused by various factors and is usually managed with antiemetic medications. Hyperglycemia, which refers to high blood sugar levels, is typically managed with appropriate diabetes management, including insulin or other glucose-lowering medications. Hand tremors can have different underlying causes, and their treatment depends on the specific etiology.
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