A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Dizziness

Crackles in the lungs

Dry, hacking cough

Hepatomegaly

Answer and Explanation

The Correct Answer is D

A. Dizziness is not a primary finding of right ventricular failure but may be associated with other conditions.

B. Crackles in the lungs are more associated with left ventricular failure.

C. Dry, hacking cough is not a primary symptom of right ventricular failure but may be seen in left-sided heart failure.

D. Hepatomegaly is a common finding in right ventricular failure due to increased pressure in the venous system.

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Correct Answer is B

Explanation

A. Inspecting for the presence of clubbing is related to chronic respiratory or cardiac conditions, not ataxia.

B. Performing a Romberg's test evaluates balance and proprioception, which is important for assessing the ability to ambulate safely in a person with ataxia.

C. Observing for the presence of Kernig's sign is used to assess for meningeal irritation, not ataxia.

D. Checking the function of cranial nerve V is related to sensation and motor function of the jaw, not to assessing ambulation or balance.

A. Educate the client that hematuria is expected following the procedure. B. Notify the provider immediately if mucus is present in the urine. C. Monitor hourly urine output. D. Apply skin barrier around the stoma site. E. Maintain the client on a fluid restriction.

Correct Answer is ["A","C","D"]

Explanation

A. Hematuria is commonly expected following an ileal conduit procedure due to the surgical intervention in the urinary tract.
B. Mucus in the urine is a normal finding after an ileal conduit procedure because the ileum secretes mucus naturally; it does not require immediate notification of the provider unless there are other concerning symptoms.
C. Monitoring hourly urine output is crucial to ensure the patency of the urinary system and to detect any early signs of complications such as obstruction or leakage.
D. Applying a skin barrier around the stoma site is essential to protect the skin from the corrosive effects of urine and to prevent skin breakdown.
E. Fluid restriction is not typically required unless specifically indicated by the provider for other medical reasons; maintaining adequate hydration is important for the client's recovery and to ensure proper urine production.

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A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

Correct Answer is B

Explanation

A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).

Correct Answer is ["A","C","D"]

Explanation

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