The nurse is caring for a client with a history of congestive heart failure. The client's dyspnea has worsened over the past 2 hours. The nurse should:

Correct Answer: B

Rationale: Placing the client in high Fowler's position eases dyspnea in worsening congestive heart failure by reducing preload oxygen adjustment needs orders, Lasix requires confirmation, and coughing won't help acute fluid overload. Nurses prioritize positioning, monitoring respiratory status, aiding comfort in this cardiac emergency.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration.

Correct Answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood.

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.