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 C
Explanation
Choice A rationale:
8 oz of fruit yogurt contains protein, but it is not as protein-rich as the other options. Yogurt is more commonly consumed for its probiotic benefits and calcium content.
Choice B rationale:
8 oz of raw spinach contains some protein but is not a high source of protein compared to the other options. Spinach is often chosen for its high iron and fiber content.
Choice C rationale:
8 oz of chopped hard-boiled egg is a significant source of protein. Eggs are well-known for their high-quality protein content.
Choice D rationale:
8 oz of brown rice is not a high source of protein compared to the other options. While it does contain some protein, it is primarily a carbohydrate-rich food.
Correct Answer is D
Explanation
Choice A rationale:
Identification is a defense mechanism where an individual associates themselves with another person or group. It does not apply to the situation described in the question.
Choice B rationale:
Reaction formation involves expressing the opposite of one's true feelings or desires. It is not the most suitable defense mechanism for the situation where the adolescent blames the teacher for their failure.
Choice C rationale:
Regression refers to reverting to an earlier stage of development in response to stress or conflict. It does not align with the adolescent's statement about their teacher disliking athletes.
Choice D rationale:
Rationalization is the defense mechanism in which a person provides logical or socially acceptable reasons for their behavior, even if these reasons are not accurate. In this case, the adolescent is rationalizing their poor performance by blaming the teacher's bias against athletes. This choice best fits the situation described.
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