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:

Decreased platelets are not typically an indicator of infection. Platelet levels may decrease in conditions like thrombocytopenia, but they are not a specific indicator of infection.

Choice B rationale:

Increased erythrocyte sedimentation rate (ESR) is an indicator of infection. An elevated ESR is a nonspecific marker of inflammation in the body, which can be seen in response to infection, among other conditions.

Choice C rationale:

Decreased hemoglobin is not typically an indicator of infection. Hemoglobin levels may decrease in conditions like anemia, but they are not a specific indicator of infection.

Choice D rationale:

Increased iron levels are not typically an indicator of infection. Iron levels can vary for various reasons, but they are not a direct marker of infection.

A. Penicillin allergy. B. Egg allergy. C. Tendonitis. D. Osteoarthritis.

Correct Answer is A

Explanation

Choice A rationale:

Reporting a penicillin allergy in the client's history is essential when the client is prescribed cefaclor. Cefaclor is a cephalosporin antibiotic, and individuals with a documented penicillin allergy may have an increased risk of cross-reactivity and allergic reactions to cephalosporin antibiotics. Therefore, it is crucial to report a penicillin allergy to the provider to evaluate the potential risks and consider alternative antibiotics if necessary.

Choice B rationale:

An egg allergy is not directly relevant to the prescription of cefaclor. While allergies to various substances can be important in healthcare, egg allergy is not a contraindication or concern when prescribing cefaclor. Therefore, it does not require specific reporting in this context.

Choice C rationale:

Tendonitis is not directly related to the prescription of cefaclor. Tendonitis is an inflammatory condition affecting tendons and is not typically a contraindication for cefaclor or other cephalosporin antibiotics.

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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?