Practice Question
A nurse was assessing a client
Answer Choices:
Correct Answer:
Reposition the client to a high Fowler's position.
Rationale:
🪑 The client is presenting with clinical signs of congestive heart failure (CHF), particularly left-sided heart failure, as evidenced by:
Tachypnea (RR 30/min)
Oxygen saturation of 90% (hypoxemia)
Wheezing throughout the lungs
Jugular vein distention, lower extremity edema, and cardiomegaly, indicating volume overload
Elevated BNP (1200 pg/mL) confirming ventricular strain
History of digoxin and furosemide administration, suggesting ongoing heart failure treatment
🪑 In this situation, the most appropriate and immediate nursing action is to reposition the client into High Fowler’s position, which uses gravity to reduce venous return, improve diaphragmatic expansion, and optimize lung ventilation.
🪑 High Fowler’s position will promote oxygenation and reduce pulmonary congestion, relieving dyspnea and work of breathing before other interventions take effect.
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This question is from RN ATI Paediatrics Nur 223a Section 4 Final Exam which contains 92 questions.
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From Exam
RN ATI Paediatrics Nur 223a Section 4 Final Exam
92 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 4