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
Explanation:
Yogurt can be beneficial for individuals with irritable bowel syndrome (IBS) because it contains probiotics, which are live bacteria that can help promote a healthy balance of gut bacteria.
Probiotics have been shown to potentially alleviate symptoms of IBS, such as bloating, gas, and abdominal discomfort. Additionally, yogurt is a good source of calcium and protein.
B- On the other hand, "Honey" is not specifically recommended for individuals with IBS as it can be a source of fermentable carbohydrates and may contribute to symptoms such as bloating and gas in some individuals.
C- "Watermelon" is generally well-tolerated by most people and can be included in the diet of individuals with IBS, as it is low in FODMAPs (fermentable carbohydrates that can trigger IBS symptoms in some individuals).
D- "Ice cream" is not typically recommended for individuals with IBS, as it often contains high amounts of fat and lactose, which can aggravate symptoms in some individuals. However, this can vary depending on the individual's tolerance to dairy and fat.
Correct Answer is C
Explanation
Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired blood clotting and an increased risk of bleeding. The use of a firm-bristled toothbrush can cause trauma to the gums and oral tissues, increasing the risk of bleeding in someone with thrombocytopenia. It is recommended for individuals with thrombocytopenia to use a soft-bristled toothbrush to minimize the risk of oral bleeding.
Wearing a face mask around others, increased intake of green, leafy vegetables, and getting an adequate amount of sleep do not directly increase the client's risk for injury in the context of thrombocytopenia. These practices are generally beneficial for overall health and well-being.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.