The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

A. Diaphragmatic breathing:

Diaphragmatic breathing, also known as abdominal or deep breathing, is a normal and effective way of breathing. It involves the contraction and relaxation of the diaphragm, allowing for efficient lung expansion. This is a healthy and efficient breathing technique.

B. Controlled breathing:

Controlled breathing refers to a deliberate and regulated breathing pattern. It can include techniques such as paced breathing, where the individual consciously controls the rate and depth of their breaths. Controlled breathing is generally considered a positive and intentional approach to managing respiratory function.

C. Pursed-lip breathing:

Pursed-lip breathing is a breathing technique where the individual breathes in through the nose and exhales through pursed lips. This method is often taught to individuals with certain respiratory conditions, such as chronic obstructive pulmonary disease (COPD), to help improve lung function and alleviate shortness of breath. Pursed-lip breathing can be a helpful strategy in specific situations.

D. Use of accessory muscles:

The use of accessory muscles indicates that the person is experiencing increased difficulty in breathing. Accessory muscles, such as the neck and shoulder muscles, are not typically heavily involved in breathing under normal circumstances. When these muscles are visibly working during breathing, it suggests increased respiratory effort and can be a sign of respiratory distress or difficulty.

A. Administer antibiotics

Administering antibiotics is not a direct intervention for preventing atelectasis. Antibiotics are typically prescribed to treat bacterial infections, and atelectasis is more related to lung collapse or incomplete lung expansion.

B. Encourage increased oral fluid intake

Adequate hydration is important for maintaining the moisture of respiratory secretions. This helps prevent mucus from becoming thick and sticky, making it easier for the patient to cough and clear the airways.

C. Early mobilization after surgery

Early mobilization, including activities such as getting out of bed and walking, helps improve lung expansion. It promotes better ventilation and prevents areas of the lungs from collapsing, reducing the risk of atelectasis.

D. Frequent turning of the patient

Turning the patient regularly is crucial for preventing pooling of respiratory secretions in dependent areas of the lungs. By changing the patient's position, nurses can facilitate drainage and ventilation throughout the lungs, minimizing the risk of atelectasis.

E. Use of incentive spirometry

Incentive spirometry is a breathing exercise device that encourages the patient to take slow, deep breaths. This helps expand the lungs and prevents atelectasis by maintaining lung volume and promoting alveolar recruitment.