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
A. I have to take this medication on an empty stomach: Pantoprazole, a proton pump inhibitor (PPI), should be taken on an empty stomach, typically 30 minutes before a meal, for optimal absorption and effectiveness in reducing stomach acid.
B. I will need to remain upright for 1 hour after taking the medication: While remaining upright after meals is recommended for individuals with GERD to prevent reflux, this is not a specific instruction related to pantoprazole. The primary concern for pantoprazole is taking it before meals.
C. I should expect to have diarrhea while taking this medication: Diarrhea is not a common side effect of pantoprazole. The most common side effects include headache, nausea, or gastrointestinal disturbances, but diarrhea is not typically expected.
D. I can take antacids at the same time as this medication: Antacids should generally not be taken at the same time as pantoprazole. Taking antacids can interfere with the absorption of pantoprazole and reduce its effectiveness. It's usually advised to space them out by at least 2 hours.
Correct Answer is A
Explanation
Explanation
Correct answer: A
A.It is important to document the location of the identification tag to ensure proper identification of the body. This is crucial for legal and administrative purposes and helps prevent any potential confusion or misidentification.
B.A copy of the client's advance directivesis an important document for healthcare providers to have during the client's care but is not typically included in the post-mortem documentation. Advance directives are typically stored separately and are more relevant to the client's care while they are alive.
C. Cause of the client's death: Determining and documenting the cause of death is typically the responsibility of the attending physician or medical examiner, not the nurse.
D.The last set of the client's vital signs in (option D) may be relevant during the client's care and treatment but may not be specifically included in the post-mortem documentation. The focus of post-mortem documentation is usually on aspects such as the cause of death, time of death, interventions performed, and any significant findings related to the client's condition or autopsy.
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