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:

Placing a padded tongue blade in the child's mouth is not recommended during a tonic-clonic seizure. This action can cause injury to the child's mouth or teeth and does not help manage the seizure itself.

Choice C rationale:

Turning the child onto their back is generally the correct action to take during a seizure to ensure an open airway. However, this should be done gently and after ensuring the child's safety. Placing a pillow under the head is also important to prevent head injury during the seizure.

Choice D rationale:

Restraining the child's upper extremities is not recommended during a tonic-clonic seizure. It can lead to injury for both the child and the healthcare provider and is not an effective way to manage the seizure. The priority is to ensure the child's safety and protect them from harm.

A. "I can take antacids at the same time as this medication.” B. "I will need to remain upright for 1 hour after taking the medication.” C. "I have to take this medication on an empty stomach.” D. "I should expect to have diarrhea while taking this medication.”

Correct Answer is C

Explanation

A. "I can take antacids at the same time as this medication.” This is generally incorrect. While antacids can provide quick relief, they can interfere with the absorption of pantoprazole. It's usually recommended to separate antacid use from pantoprazole by at least a couple of hours.
B. "I will need to remain upright for 1 hour after taking the medication.” This is incorrect. This is a common instruction for general GERD management, but not specifically related to taking the pantoprazole medication itself.
C. "I have to take this medication on an empty stomach.” This is generally correct. PPIs like pantoprazole work best when taken before meals, typically 30-60 minutes before breakfast. This allows the medication to be absorbed and ready to reduce acid production when you eat.
D. "I should expect to have diarrhea while taking this medication.” While diarrhea can be a side effect of pantoprazole, it's not a guaranteed or expected outcome.

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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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Naxlex Comprehensive Predictor Exams

A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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?