A nurse is assessing a client with congestive heart failure. Which finding indicates possible fluid accumulation in the lungs, a common symptom of CHF?
Wheezing on auscultation
Hyperactive bowel sounds
Absence of jugular vein distention
Crackles on auscultation
The Correct Answer is D
A) This choice is incorrect because wheezing on auscultation is a characteristic finding in respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not congestive heart failure.
B) This choice is incorrect because hyperactive bowel sounds are not specific to congestive heart failure and are more indicative of gastrointestinal activity.
C) This choice is incorrect because the absence of jugular vein distention is not directly related to fluid accumulation in the lungs. Jugular vein distention is associated with right-sided heart failure.
D) This choice is correct. Crackles, also known as rales, are abnormal lung sounds heard on auscultation and may indicate fluid accumulation in the lungs, a common symptom of congestive heart failure. The presence of crackles suggests pulmonary congestion due to fluid leaking into the alveoli.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because restricting all physical activity is not recommended for clients with congestive heart failure. Regular, moderate exercise can be beneficial for heart health when appropriately prescribed by the healthcare provider.
B) This choice is correct. Regularly weighing themselves, ideally daily, and reporting sudden weight gain to the healthcare provider is essential for clients with congestive heart failure. Sudden weight gain may indicate fluid retention, a worsening of heart failure, or medication non-compliance.
C) This choice is incorrect because a high-sodium diet can worsen fluid retention and exacerbate congestive heart failure symptoms. The client should follow a low-sodium diet to manage fluid balance.
D) This choice is incorrect because taking prescribed medications only when symptoms worsen is not appropriate for congestive heart failure management. The client should take prescribed medications as directed by the healthcare provider, even when feeling well, to prevent symptom exacerbation and improve heart function.
Correct Answer is C
Explanation
A) This choice is incorrect because hypertension is not a common side effect of digoxin. Digoxin is used to treat heart failure and can help control blood pressure in some cases.
B) This choice is incorrect because hyperkalemia (elevated potassium levels) is not a common side effect of digoxin. In fact, digoxin can sometimes cause hypokalemia (low potassium levels) as a side effect.
C) This choice is correct. Bradycardia (slow heart rate) is a common side effect of digoxin. Digoxin works by increasing the force of the heart's contractions and can slow down the heart rate. Clients taking digoxin should have their heart rate monitored regularly, and the healthcare provider should be notified if the heart rate is below the prescribed parameters.
D) This choice is incorrect because respiratory alkalosis is not a common side effect of digoxin. Digoxin does not directly affect the respiratory system.
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