A client with congestive heart failure presents with swollen ankles, legs, and abdomen. The nurse should document these findings as:

Clubbing

Peripheral edema

Pitting edema

Ascites

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because clubbing refers to the enlargement of the fingertips and nails due to chronic hypoxia, which is not related to the client's reported symptoms.

B) This choice is correct. Peripheral edema refers to swelling in the legs, ankles, and feet, which is a common symptom of congestive heart failure. The client's symptoms of swollen ankles, legs, and abdomen indicate peripheral edema.

C) This choice is incorrect because pitting edema is a specific type of edema where pressure on the skin leaves an indentation or "pit." While the client's edema may indeed be pitting, the question does not provide enough information to confirm this.

D) This choice is incorrect because ascites is the accumulation of fluid in the abdominal cavity and is not specific to the client's reported symptoms of swollen ankles and legs.

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Correct Answer is D

Explanation

A) This choice is incorrect because hemoptysis refers to coughing up blood from the respiratory tract, which is not described by the client.

B) This choice is incorrect because dyspnea refers to difficulty breathing or shortness of breath, not a dry, persistent cough.

C) This choice is incorrect because paroxysmal nocturnal dyspnea is characterized by sudden breathlessness that awakens the client from sleep, not a dry cough.

D) This choice is correct. Cardiac asthma is a form of wheezing or coughing that occurs as a result of fluid accumulation in the lungs due to congestive heart failure. It is not caused by asthma but is a manifestation of heart failure impacting the respiratory system.

Questions

A. Monitor blood pressure daily and adjust the dose accordingly. B. Avoid foods high in potassium while on this medication. C. Take the medication with a glass of grapefruit juice. D. Limit fluid intake to prevent fluid overload.

Correct Answer is A

Explanation

A) This choice is correct. ACE inhibitors are used to lower blood pressure and reduce the workload on the heart. The client should monitor their blood pressure regularly and report any significant changes to their healthcare provider. Adjustments to the medication dosage should only be made under the guidance of the healthcare provider.

B) This choice is incorrect because while ACE inhibitors can increase potassium levels, avoiding foods high in potassium is not necessary unless specifically directed by the healthcare provider. The client should follow a balanced diet and inform the healthcare provider of any changes in their dietary habits.

C) This choice is incorrect because ACE inhibitors should not be taken with grapefruit juice. Grapefruit juice can interfere with the metabolism of the medication, leading to increased levels and potential side effects.

D) This choice is incorrect because limiting fluid intake is not specific to the administration of ACE inhibitors. Fluid intake may need to be adjusted based on the client's overall fluid balance and congestive heart failure status, but it is not a direct instruction related to the medication.

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A client with congestive heart failure presents with swollen ankles, legs, and abdomen. The nurse should document these findings as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with congestive heart failure presents with a dry, persistent cough. The nurse should recognize this symptom as:

Correct Answer is D

Explanation

A nurse is providing education to a client with congestive heart failure who is prescribed an angiotensin-converting enzyme (ACE) inhibitor. The nurse should instruct the client to:

Correct Answer is A

Explanation

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