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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.
Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.
Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary. The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions. It is not advisable to skip a dose of phenytoin without consulting a healthcare provider.
Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.
Correct Answer is C
Explanation
Nausea and vomiting are common side effects of doxycycline, an antibiotic commonly used to treat chlamydial infections. Taking the medication with food or a snack can help alleviate these side effects. The recommendation to take the medication with crackers provides a light source of carbohydrates that can help settle the stomach and reduce nausea.
It is generally not recommended to take doxycycline with calcium-rich foods or beverages, as they can interfere with the absorption of the medication. Calcium can form complexes with doxycycline, reducing its effectiveness. Therefore, it is best to avoid calcium-rich foods and beverages, including calcium-fortified orange juice, when taking doxycycline.
Similar to calcium-rich foods, antacids can also interfere with the absorption of doxycycline. Antacids contain aluminum, magnesium, or calcium, which can bind to doxycycline and reduce its effectiveness. Therefore, it is generally recommended to avoid taking doxycycline with antacids.
While it is important to remain upright for a short period after taking some medications to prevent reflux or aspiration, this recommendation may not specifically address the client's nausea and vomiting. Taking the medication with food, such as crackers, may be more effective in alleviating the symptoms.
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