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."
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.
B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.
C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.
D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.
Correct Answer is B
Explanation
A. Drinking water in hot weather is important to prevent dehydration. This is not a risk factor for metabolic alkalosis unless the client is excessively losing electrolytes through sweating and not replacing them.
B. Sodium bicarbonate is an alkaline substance, and regular use, especially after meals, can contribute to metabolic alkalosis. The client should be instructed on the potential risks of using sodium bicarbonate too frequently.
C. Avoiding milk due to gastrointestinal symptoms does not directly contribute to metabolic alkalosis.
D. Digoxin does not directly affect acid-base balance, but it requires monitoring due to potential interactions with other medications or electrolyte imbalances.
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