A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath. and a respiratory rate of 24/min. Which of the following actions should the nurse take?

Rationale: A. Maintain the client in high-Fowler's position: Placing the client in high-Fowler's position improves lung expansion and decreases pulmonary congestion by lowering venous return to the heart. This is a priority intervention for managing dyspnea and crackles in heart failure. B. Increase the client's intake of oral fluids: Increasing fluid intake may worsen fluid overload in clients with heart failure. These clients typically require fluid restrictions to prevent exacerbation of symptoms like pulmonary edema. C. Instruct the client to cough every 4 hr: While coughing can help clear secretions, the symptoms in this scenario are related to fluid overload, not mucus accumulation. Coughing alone will not relieve the pulmonary congestion seen in heart failure. D. Encourage the client to ambulate to loosen secretions: Ambulation has benefits but is not the first action when the client is short of breath and showing signs of pulmonary congestion. Activity should be limited until respiratory status stabilizes.