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:
Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.
Choice B rationale:
Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.
Choice C rationale:
Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.
Choice D rationale:
Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.
Correct Answer is B
Explanation
Choice A rationale:
The statement, "You will no longer be infectious once you have completed a course of antibiotics," is incorrect. Genital herpes is a viral infection caused by the herpes simplex virus (HSV) Antibiotics do not treat viral infections, including herpes. Antiviral medications are used for herpes management, but they do not cure the infection. The virus can remain dormant in the body and reactivate.
Choice B rationale:
"You should increase fluid intake to relieve dysuria" is a correct and important piece of advice. Dysuria (painful urination) can be a symptom of genital herpes. Increasing fluid intake helps dilute urine, reducing discomfort during urination.
Choice C rationale:
"You should have the lesions drained as they appear" is incorrect. Lesion drainage is not a standard treatment for genital herpes. Antiviral medications are typically prescribed to manage outbreaks and reduce their duration and severity.
Choice D rationale:
"You should wear nylon underwear until the lesions have healed" is not the recommended guidance. Wearing loose-fitting cotton underwear is generally advised for comfort and to minimize irritation during a herpes outbreak. Nylon underwear may cause friction and discomfort.
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