A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Increased pulmonary artery wedge pressure (PAWP).

Elevated central venous pressure (CVP).

Decreased brain natriuretic peptide (BNP).

Decreased specific gravity

Answer and Explanation

The Correct Answer is B

Right-sided heart failure is a condition in which the right ventricle fails to pump blood eﬀectively to the lungs, causing a backup of blood in the systemic circulation. This leads to increased pressure in the right atrium and the vena cava, which can be measured by the central venous pressure (CVP). A normal CVP is 2 to 6 mm Hg, but in right-sided heart failure, it can rise above 10 mm Hg. Symptoms of right-sided heart failure include peripheral edema, jugular venous distension, hepatomegaly, ascites, and weight gain.

a. Increased pulmonary artery wedge pressure (PAWP). This statement is incorrect because it describes a finding of left-sided heart failure, not right-sided heart failure. Left-sided heart failure is a condition in which the left ventricle fails to pump blood eﬀectively to the systemic circulation, causing a backup of blood in the pulmonary circulation. This leads to increased pressure in the left atrium and the pulmonary capillaries, which can be measured by the pulmonary artery wedge pressure (PAWP). A normal PAWP is 6 to 12 mm Hg, but in left-sided heart failure, it can rise above 18 mm Hg. Symptoms of left-sided heart failure include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles in the lungs, and pink frothy sputum.

c. Decreased brain natriuretic peptide (BNP). This statement is incorrect because it describes a finding of normal or reduced cardiac function, not heart failure. Brain natriuretic peptide (BNP) is a hormone secreted by the cardiac cells in response to increased stretch and pressure in the ventricles. It acts as a diuretic and a vasodilator, lowering blood volume and blood pressure. BNP is used as a biomarker for diagnosing and monitoring heart failure, as it reﬂects the degree of ventricular dysfunction. A normal BNP level is less than 100 pg/mL, but in heart failure, it can rise above 400 pg/mL.

d. Decreased specific gravity. This statement is incorrect because it describes a finding of dilute urine, not concentrated urine. Specific gravity is a measure of the concentration of solutes in urine, reﬂecting the ability of the kidneys to regulate ﬂuid balance. A normal specific gravity is 1.005 to 1.030, but it can vary depending on ﬂuid intake and output, hydration status, and renal function. In right-sided heart failure, ﬂuid retention and reduced renal perfusion can cause oliguria and increased specific gravity of urine.

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Correct Answer is D

Explanation

Hemorrhagic stroke is a type of stroke that occurs when a blood vessel ruptures in the brain, causing bleeding and increased intracranial pressure. The client's symptoms of sudden, severe headache, vomiting, seizure, and

unresponsiveness are consistent with hemorrhagic stroke. The client's elevated blood pressure and temperature are also risk factors for hemorrhagic stroke.

Thrombotic stroke is a type of stroke that occurs when a blood clot forms in an artery that supplies blood to the brain, causing ischemia and tissue damage. The client's symptoms are not typical of thrombotic stroke, which usually has a gradual onset and aﬀects one side of the body.

Transient ischemic atack (TIA) is a temporary interruption of blood ﬂow to the brain, causing neurologic deficits that resolve within 24 hours. The client's symptoms are not indicative of TIA, which does not cause loss of consciousness or permanent brain damage.

Embolic stroke is a type of stroke that occurs when a blood clot or other debris travels from another part of the body to the brain, causing occlusion and ischemia. The client's symptoms are not characteristic of embolic stroke, which usually has a sudden onset and aﬀects one side of the body.

A. Ask the client if any other foods cause such a reaction. B. Notify the provider of the client's allergy. C. Notify the dietary department of the client's allergy. D. Atach a wrist band indicating the client's allergy.

Correct Answer is B

Explanation

The priority nursing action is to notify the provider of the client's allergy because shellfish allergy may indicate an allergy to iodine, which is commonly used as a contrast dye in cardiac catheterization. This could cause a severe allergic reaction or anaphylaxis during the procedure, which could be life-threatening. The provider may need to order a diﬀerent type of contrast dye or premedicate the client with antihistamines or steroids to prevent an allergic reaction.

a. Ask the client if any other foods cause such a reaction is wrong because it is not the priority action and it does not address the potential risk of iodine allergy.

c. Notify the dietary department of the client's allergy is wrong because it is not relevant to the cardiac catheterization and it does not prevent an allergic reaction during the procedure.

d. Atach a wrist band indicating the client's allergy is wrong because it is not sufficient to alert the provider or the catheterization team of the client's allergy and it does not prevent an allergic reaction during the procedure.

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A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?

Correct Answer is B

Explanation

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