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.This requires intervention because creases in the stockings can create pressure points that may lead to skin irritation or impaired circulation. The stockings should be applied smoothly and evenly to ensure proper compression and to avoid skin complications.
b.This is not necessary and can actually be incorrect. Antiembolic stockings should be applied with the correct side facing the client's skin. Turning them inside out could alter their effectiveness in providing the required compression.
c.This is appropriate. Applying antiembolic stockings before the client gets out of bed is recommended because it helps to promote venous return and prevent blood clots, especially if the client is immobile or has limited mobility.
d.This is appropriate. Asking the client to point their toes helps to ensure that the stockings can be applied correctly and fit well, reducing the risk of creating pressure points or causing discomfort.
Correct Answer is C
Explanation
Overhearing a discussion about a client's private information is a breach of confidentiality, and it is the nurse's responsibility to address the situation promptly.
While documenting the event in the client's progress notes might be necessary in some cases, it is not the initial action to take in this scenario. Similarly, submitting an incident report to the risk manager may be required for documentation purposes, but it is not the immediate action to address the breach of confidentiality.
Informing the client of the APs' actions may not be necessary unless there is evidence that the client's privacy has been compromised or if the client specifically requests to know. However, the priority is to address the issue of the conversation between the APs and ensure that confidentiality is maintained.
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