A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right- sided heart failure?

"My shoes fit really tight lately."

"I sleep with 2 pillows at night."

"I have trouble catching my breath."

"I wake up coughing every night."

Answer and Explanation

The Correct Answer is A

A. Tight shoes may indicate fluid retention in the lower extremities, which is a common symptom of right-sided heart failure. This condition leads to the backup of blood into the systemic circulation, causing peripheral edema.

B. Sleeping with two pillows may indicate left-sided heart failure, as the client may be experiencing orthopnea (difficulty breathing when lying flat).

C. Shortness of breath is more commonly associated with left-sided heart failure.

D. Waking up coughing every night is also a sign of left-sided heart failure, where pulmonary congestion leads to nocturnal coughing.

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Correct Answer is D

Explanation

A. Testicular torsion: While testicular torsion is an emergency and can cause pain and damage, it is not directly linked to testicular cancer risk.

B. Sexually transmitted infections: Although STIs can affect reproductive health, they are not a known significant risk factor for testicular cancer.

C. Testicular trauma: Testicular trauma may cause injury but is not a major risk factor for testicular cancer.

D. Undescended testicles: This is the correct answer. Undescended testicles, or cryptorchidism, is a well-established risk factor for testicular cancer, as it increases the likelihood of developing the condition.

A. Administer oxygen at 2 L/min. B. Obtain a bedside commode. C. Suggest the client use a bedpan. D. Allow continued bathroom privileges.

Correct Answer is B

Explanation

A. Administering oxygen is unnecessary at this time, as the client’s oxygen saturation is normal at 96%.

B. The client has had a myocardial infarction, which can lead to complications such as orthostatic hypotension or cardiovascular strain with sudden position changes. A bedside commode minimizes the need for the client to get out of bed and reduces the risk of these complications.

C. Suggesting the use of a bedpan may be an alternative but is less comfortable and may not adequately address the risk of strain from getting out of bed.

D. Allowing continued bathroom privileges may be unsafe, as it may increase the risk of a fall or cardiovascular strain.

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A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right- sided heart failure?

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