Question

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. what is the priority nursing intervention?

Answer 1

The correct answer would be - place the client in a high fowler's position.

Step-by-step explanation:

As the condition here explains that the client has tachypnea that is a condition of breathing disorder characterized by fast and shallow breathing. The other case in the client is bilateral crackles which are a condition of breathing problems due to collapsing alveoli as proper breathing is not happening.

In both cases, the most likely nurse should place the client in a high fowler's position that is a position in which client bed in hospital particularly elevated in between 60 to 90 degrees from the head to relax the stress of muscles that took place.

Thus, the correct answer is - place the client in a high fowler's position.

Answer 2

There are choices for this question namely:

1. Initiate oxygen therapy
2. Assess for a pleural friction rub
3. Obtain a chest x-ray film immediately
4. Place the client in a fowler's position

The correct answer is that the nurse should "place the client in a fowler's position". The fowler's position is a position wherein the head and chest of the patient is elevated more than the lower extremities. In a patient with heart failure with tachypnea and bilateral crackles, the nurse should suspect pulmonary edema. By placing the patient in a fowler's position, the edema fluid in the lungs will gravitate towards the lower extremities, reducing pulmonary edema and reducing symptoms of dyspnea and tachypnea.