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 A
Explanation
Choice A rationale:
The nurse should encourage the client to be assertive. Dependent Personality Disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. One of the treatment goals is to help the client develop assertiveness skills to reduce their dependence on others. Encouraging assertiveness allows the client to express their needs and make decisions for themselves, which is an essential aspect of their therapeutic journey toward independence.
Choice B rationale:
Assuming responsibility for making the client's decisions would not be appropriate. It would further reinforce the client's dependent behavior and hinder their progress towards independence. The goal of therapy is to promote autonomy and self-reliance, not to perpetuate dependency.
Choice C rationale:
Maintaining a verbal no-harm contract with the client may be necessary in some cases, especially if the client exhibits self-harming behaviors. However, it is not a primary teaching point when educating the caregiver about managing a client with Dependent Personality Disorder. The focus should primarily be on helping the client develop assertiveness and self-reliance.
Choice D rationale:
Limiting the client's social interactions is not an appropriate intervention. Social support can be beneficial for individuals with Dependent Personality Disorder, as it can help them build self-confidence and reduce their excessive reliance on one individual. Isolating the client would not be in their best interest.
Correct Answer is C
Explanation
Choice A rationale:
Tilt your head forward while inhaling is not an appropriate instruction for using an albuterol metered-dose inhaler (MDI) In fact, it is recommended to keep the head in a neutral position while using an MDI to ensure proper delivery of the medication to the lungs. Tilted head positions can lead to ineffective inhalation and may result in the medication being deposited in the mouth or throat rather than reaching the lungs. Therefore, choice A is not the correct answer.
Choice B rationale:
Exhale immediately after inhaling is not an accurate instruction for using an albuterol MDI. The correct sequence is to inhale slowly and deeply through the mouth while pressing down on the canister to release the medication, hold the breath for a few seconds (usually 10 seconds), and then exhale slowly. Exhaling immediately after inhaling would not allow the medication to reach the lower airways effectively. Therefore, choice B is not the correct answer.
Choice C rationale:
"Close your mouth around the mouthpiece" is an essential instruction for using an albuterol MDI correctly. It ensures that the medication
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