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?

Increase the client's intake of oral fluids.

Instruct the client to cough every 4 hr.

Maintain the client in high-Fowler's position.

Encourage the client to ambulate to loosen secretions.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Increasing the client's intake of oral fluids may not address the underlying issue of crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. This client likely has fluid accumulation in the lungs, and simply increasing fluid intake could exacerbate the problem. It's important to assess and manage the client's fluid balance carefully.

Choice B rationale:

Instructing the client to cough every 4 hours may not be sufficient for managing the client's symptoms, especially if there is fluid in the lungs. Coughing alone may not adequately clear the airways. More intensive interventions are needed.

Choice C rationale:

The correct action is to "Maintain the client in high-Fowler's position." High-Fowler's position helps improve lung expansion and oxygenation by allowing the client to sit up at an angle, which reduces pressure on the diaphragm and improves lung mechanics. This position can help alleviate symptoms such as crackles and shortness of breath in clients with heart failure.

Choice D rationale:

Encouraging the client to ambulate to loosen secretions may not be appropriate in this case. Ambulation is generally encouraged for clients with adequate oxygenation and mobility. If the client has severe respiratory distress, it's crucial to address that issue first before considering ambulation.

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Correct Answer is B

Explanation

Choice A rationale:

The administration of Rh(D) immune globulin (RhoGAM) is typically indicated for Rh-negative mothers who are carrying Rh-positive fetuses to prevent sensitization to Rh antigens. It is not directly related to the amniocentesis procedure. Therefore, this information is not necessary for the client undergoing an amniocentesis.

Choice B rationale:

This is the correct answer. Having an empty bladder is crucial during an amniocentesis procedure because a full bladder can obscure visualization of the fetus and the needle placement. It is essential for a successful and safe procedure. The nurse should instruct the client to empty their bladder before the test.

Choice C rationale:

The position during an amniocentesis is typically dorsal recumbent or semi-Fowler's position to allow for proper visualization of the fetus and needle placement. Lying on the left side is not a standard position for this procedure, so this information is incorrect and not necessary for the client.

Choice D rationale:

Drinking 50 grams of oral glucose is not a requirement for an amniocentesis procedure. This information is unrelated to the amniocentesis and can be confusing for the client. Therefore, it is not necessary to include this in the instructions.

A. Elevates the legs before applying the stockings. B. Measures the client's calf circumference before selecting the stocking size. C. Applies lotion to the client's legs before putting on the stockings. D. Rolls down the stockings from the thigh to the ankle.

Correct Answer is ["A","B"]

Explanation

A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.

B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.

C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.

D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.

So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.

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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?

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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?