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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A stable client with chronic angina is not in immediate danger, and the scheduled dose of nifedipine is not an urgent priority.
B. The client with unstable angina who has just undergone a heart catheterization with balloon angioplasty requires immediate assessment for complications such as bleeding, clot formation, or re-occlusion of the artery.
C. The 65-year-old post-MI client is stable, and while their anxiety is important to address, it is not an immediate concern compared to other clients.
D. The client post-coronary artery bypass with a potassium level of 4.2 mEq/L is stable and does not require urgent intervention.
Correct Answer is A
Explanation
A. Assessing respiratory status is the priority in heart failure exacerbation, as respiratory distress can rapidly worsen and affect oxygenation.
B. While knowing current medications is important, the priority in this situation is addressing the client's respiratory needs.
C. Administering furosemide is part of the management plan but should follow the initial assessment of the client's condition, especially respiratory status.
D. Drawing blood is helpful but not the immediate priority in managing acute heart failure exacerbation.
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