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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Ice cream. Ice cream is not typically recommended for individuals with irritable bowel syndrome (IBS) as it contains dairy, which can exacerbate gastrointestinal symptoms in some people with lactose intolerance or dairy sensitivity. It may also be high in sugar, which can worsen IBS symptoms for some individuals.
Choice B rationale:
Honey. Honey is generally well-tolerated by individuals with IBS and can be used as a natural sweetener in moderation. However, it is not specifically recommended as a dietary inclusion for managing IBS symptoms.
Choice C rationale:
Watermelon. Watermelon is a low-fiber fruit that may be well-tolerated by some individuals with IBS, especially during periods of symptom flare-ups. However, it does not provide the beneficial probiotics and digestive enzymes found in yogurt, which can be helpful for some IBS patients.
Choice D rationale:
Yogurt. Yogurt, especially varieties containing live probiotic cultures, can be beneficial for individuals with IBS. Probiotics may help improve gut health and alleviate some gastrointestinal symptoms associated with IBS. It is often recommended as a dietary inclusion for those with IBS.
Correct Answer is D
Explanation
Choice A rationale:
Children who have erythema infectiosum (fifth disease) require short-term antibiotic therapy. Erythema infectiosum, also known as fifth disease, is caused by a virus and does not require antibiotic therapy. It is a self-limiting illness that does not respond to antibiotics.
Choice B rationale:
Administration of childhood immunizations will prevent exanthem subitum (roseola infantum) Exanthem subitum, or roseola infantum, is typically a viral illness and is not prevented by childhood immunizations. It is caused by human herpesvirus 6 (HHV-6) and human herpesvirus 7 (HHV-7)
Choice C rationale:
Restrict fluids for children who have pertussis. Restricting fluids for children with pertussis is not recommended. Pertussis, also known as whooping cough, can cause severe coughing spells, and it is important to ensure that affected children stay well-hydrated. Restricting fluids can lead to dehydration, which can worsen the condition.
Choice D rationale:
Isolate children who have varicella until the vesicles have formed crusts. Isolation of children with varicella (chickenpox) until the vesicles have formed crusts is a standard infection control measure. Varicella is highly contagious, and isolating affected individuals helps prevent the spread of the virus to others. Once the vesicles have crusted over, the risk of transmission is significantly reduced.
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