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?

A. Instruct the client to cough every 4 hr: While coughing can help clear secretions, the client’s symptoms indicate fluid overload and pulmonary congestion. Encouraging coughing alone will not improve oxygenation or reduce pulmonary edema. B. Increase the client's intake of oral fluids: Increasing fluids can worsen fluid overload in heart failure, exacerbating pulmonary congestion, crackles, and dyspnea. Fluid restriction may be indicated depending on the client’s status. C. Maintain the client in high-Fowler's position: High-Fowler’s position promotes lung expansion, reduces venous return, and improves ventilation in clients with pulmonary congestion. This position helps relieve dyspnea and optimizes oxygenation, making it the priority intervention. D. Encourage the client to ambulate to loosen secretions: Ambulation increases oxygen demand and cardiac workload, which may worsen shortness of breath and pulmonary congestion in heart failure. Activity should be limited until the client is stabilized.