Question

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations for the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

a. A bedside commode is positioned near the bed
b. A full pitcher of water is on the bedside table
c. A low sodium diet tray was brought to the room
d. The client is lying in the supine position in bed
e. A saline lock is present in the right forearm

Answer 1

Observations requiring intervention include a full pitcher of water at the bedside, potentially increasing the risk of fluid overload, and the client lying in the supine position, which may aggravate respiratory issues. Other observations listed typically align with proper care guidelines.

Step-by-step explanation:

A client admitted with an exacerbation of heart failure secondary to COPD might require immediate nursing interventions for several observations. Of the options listed:

A full pitcher of water on the bedside table should be carefully evaluated, as excessive fluid intake can lead to worsening heart failure symptoms due to fluid overload.

• The client is lying in the supine position in bed could also be problematic because this position may exacerbate respiratory distress by increasing pressure on the diaphragm, which could be compromised by the COPD condition. Propping the patient in a semi-upright position, like Fowler's or semi-Fowler's, can aid breathing.

The othe matchup with the patient's needs: a bedside commode reduces the need for exertion to get to the bathroom, a low sodium diet tray is appropriate as it may help to control fluid retention, and a saline lock in the forearm ensures IV access if needed without contributing direct harm.