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

Answer and Explanation

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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Correct Answer is C

Explanation

A) This choice is incorrect because age is a non-modifiable risk factor for congestive heart failure. While age increases the risk of heart disease, including CHF, it cannot be changed or modified.

B) This choice is incorrect because family history of heart disease is a non-modifiable risk factor. While individuals with a family history of heart disease may have an increased risk of developing CHF, it is not something that can be changed or modified.

C) This choice is correct. Smoking is a modifiable risk factor for congestive heart failure. Smoking damages blood vessels, increases blood pressure, and can lead to atherosclerosis, all of which contribute to heart failure.

D) This choice is incorrect because gender is a non-modifiable risk factor for congestive heart failure. While men may have a slightly higher risk of heart failure compared to women, gender is not something that can be changed or modified.

A. Monitor blood pressure daily and adjust the dose accordingly. B. Avoid foods high in potassium while on this medication. C. Take the medication with a glass of grapefruit juice. D. Limit fluid intake to prevent fluid overload.

Correct Answer is A

Explanation

A) This choice is correct. ACE inhibitors are used to lower blood pressure and reduce the workload on the heart. The client should monitor their blood pressure regularly and report any significant changes to their healthcare provider. Adjustments to the medication dosage should only be made under the guidance of the healthcare provider.

B) This choice is incorrect because while ACE inhibitors can increase potassium levels, avoiding foods high in potassium is not necessary unless specifically directed by the healthcare provider. The client should follow a balanced diet and inform the healthcare provider of any changes in their dietary habits.

C) This choice is incorrect because ACE inhibitors should not be taken with grapefruit juice. Grapefruit juice can interfere with the metabolism of the medication, leading to increased levels and potential side effects.

D) This choice is incorrect because limiting fluid intake is not specific to the administration of ACE inhibitors. Fluid intake may need to be adjusted based on the client's overall fluid balance and congestive heart failure status, but it is not a direct instruction related to the medication.

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A nurse is assessing a client with congestive heart failure. Which finding indicates possible fluid accumulation in the lungs, a common symptom of CHF?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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