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 wheezing on auscultation is a characteristic finding in respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not congestive heart failure.

B) This choice is incorrect because hyperactive bowel sounds are not specific to congestive heart failure and are more indicative of gastrointestinal activity.

C) This choice is incorrect because the absence of jugular vein distention is not directly related to fluid accumulation in the lungs. Jugular vein distention is associated with right-sided heart failure.

D) This choice is correct. Crackles, also known as rales, are abnormal lung sounds heard on auscultation and may indicate fluid accumulation in the lungs, a common symptom of congestive heart failure. The presence of crackles suggests pulmonary congestion due to fluid leaking into the alveoli.

A. "Take the medication with a glass of grapefruit juice." B. "Monitor your blood pressure daily and adjust the dose accordingly." C. "Report any persistent cough or difficulty breathing to your healthcare provider." D. "Avoid foods high in potassium while on this medication."

Correct Answer is C

Explanation

A) 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.

B) This choice is incorrect because the client should not adjust the dose of the ACE inhibitor without consulting their healthcare provider. Blood pressure should be monitored, but any dosage adjustments should be made by the healthcare provider based on the client's response to the medication.

C) This choice is correct. ACE inhibitors can cause a side effect of a persistent dry cough, and in some cases, difficulty breathing. The client should promptly report these symptoms to their healthcare provider for evaluation and possible adjustment of the medication regimen.

D) 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.

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

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with congestive heart failure. Which finding indicates possible fluid accumulation in the lungs, a common symptom of CHF?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client with congestive heart failure. The client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. Which instruction is essential for the client to follow?

Correct Answer is C

Explanation

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