MSC NCLEX Physiological Integrity Related

Review MSC NCLEX Physiological Integrity related questions and content

A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. Which nursing measure should the nurse implement to increase the client's comfort until specific therapy is prescribed by the primary health care provider?

  • A. Cover the client with warm blankets.
  • B. Minimize visual and auditory stimuli present.
  • C. Elevate the client's head to at least 45 degrees.
  • D. Administer oxygen at 4 L per minute by nasal cannula.
Correct Answer: C

Rationale: Excess fluid volume can lead to symptoms such as shortness of breath and cerebral edema, which can be alleviated by elevating the head of the bed to at least 45 degrees to promote venous drainage and reduce intracranial pressure. This is a safe and effective nursing intervention to increase comfort until specific medical therapy is prescribed.