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 B

Explanation

A. Assessing oral temperature is not a priority immediately after an electrical burn, as the focus should be on monitoring for cardiac issues and other life-threatening conditions.

B. Electrical burns can cause cardiac arrhythmias, including dysrhythmias like ventricular fibrillation, which can be life-threatening. The nurse should place the client on a cardiac monitor immediately to detect any abnormal rhythms and respond accordingly.

C. While checking potassium levels is important for assessing potential complications such as kidney damage or arrhythmias, cardiac monitoring should take precedence.

D. Assessing for pain at contact points is important, but it is secondary to ensuring cardiac stability in an electrical burn victim.

A. "Clean the skin and clip hairs if needed." B. "Turn off oxygen prior to monitoring the client." C. "Place the electrodes on the posterior chest." D. "Add gel to the electrodes prior to applying them."

Correct Answer is A

Explanation

A. Cleaning the skin and clipping hairs ensures good electrode contact, which is essential for accurate ECG readings. This is the correct statement.

B. Oxygen should not be turned off unless specifically instructed by a provider. It does not interfere with ECG monitoring.

C. Electrodes should be placed on the anterior chest for standard ECG monitoring, not on the posterior chest.

D. Electrodes for ECG monitoring typically come with adhesive backing and do not require additional gel.

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Test Name	Results	Reference Range
WBC	12, 000	4, 000- 11, 000
Na+	149 mEq/L	135-145 mEq/L
K+	5.0 mEq/L	3.5- 5.0 mEq/L
Cl-	110 mEq/L	96-106 mEq/L
pH	7.34	7.35-7.45
PaCO2	34 mmHg	35- 45 mmHg
PaO2	78 mm Hg	80-100 mmHg
HCO3	21 mEq/L	22- 26 mEq/L

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?

Nursing Test Bank

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