A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Hacking cough
Abdominal distension
Dependent edema
Jugular venous distention
The Correct Answer is A
A. Hacking cough: This is the correct answer. Left-sided heart failure can lead to pulmonary congestion, resulting in a cough that is often described as "hacking" or "persistent." This cough may be worse at night when the client is lying down.
B. Abdominal distension: Abdominal distension is more commonly associated with right-sided heart failure, as fluid accumulates in the abdomen (ascites). In left-sided heart failure, fluid accumulates in the lungs, leading to pulmonary symptoms.
C. Dependent edema: Dependent edema is also more commonly associated with right-sided heart failure. In left-sided heart failure, fluid tends to accumulate in the lungs, causing pulmonary congestion and related symptoms.
D. Jugular venous distention: Jugular venous distention is often seen in right-sided heart failure due to impaired blood flow from the right atrium into the right ventricle. This finding is less likely to be prominent in left-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct answer: C
A. Bumetanide 1 mg IV bolus every 12 hr is a loop diuretic used to help reduce fluid overload and manage heart failure symptoms. This medication helps remove excess fluid from the body and can be beneficial for a client with acute heart failure following an MI.
B. Laboratory testing of serum potassium upon admission: It is common to monitor serum potassium levels in patients receiving diuretics, especially loop diuretics, to prevent electrolyte imbalances.
C.Administering 0.9% normal saline IV at a continuous rate can potentially exacerbate heart failure by increasing fluid volume, leading to fluid overload and worsening symptoms. In acute heart failure, fluid management is critical, and fluids are typically restricted to prevent further strain on the heart.
D. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain: Morphine sulfate is prescribed for pain management and is commonly used in acute heart failure situations to relieve anxiety and decrease preload on the heart. The dosing frequency is appropriate as "every 2 hr PRN" indicates it should be administered as needed for pain relief.
Correct Answer is B
Explanation
A. Aplastic anemia results in an inability to absorb vitamin B12: This statement is incorrect. Aplastic anemia is not related to the absorption of vitamin B12. It primarily involves a decrease in the production of blood cells by the bone marrow.
B. Aplastic anemia results from decreased bone marrow production of RBCs: This is the correct information. Aplastic anemia is a condition characterized by the failure of the bone marrow to produce an adequate number of blood cells, including red blood cells (RBCs), white blood cells (WBCs), and platelets.
C. Aplastic anemia results in an increased rate of RBC destruction: This statement is incorrect. Aplastic anemia is not associated with an increased rate of RBC destruction. Instead, it is characterized by a reduction in the number of blood cells produced by the bone marrow.
D. Aplastic anemia is associated with a decreased intake of iron: This statement is incorrect. Aplastic anemia is not related to a decreased intake of iron. It is primarily a disorder of bone marrow function leading to insufficient production of blood cells.
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