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 D

Explanation

A) This choice is incorrect because a body mass index (BMI) of 22 kg/m² is within the normal range and is not directly associated with the development of congestive heart failure in this scenario.

B) This choice is incorrect because a blood pressure of 120/80 mmHg is within the normal range and does not indicate a direct precipitating factor for congestive heart failure in this case.

C) This choice is incorrect because a fasting blood glucose level of 90 mg/dL is within the normal range and is not directly associated with the development of congestive heart failure in this scenario.

D) This choice is correct. A serum cholesterol level of 240 mg/dL indicates high cholesterol, which is a risk factor for coronary artery disease. Coronary artery disease is a leading cause of congestive heart failure and may have contributed to the client's condition.

A. "Consume a diet high in sodium to prevent fluid retention." B. "Limit your intake of fluids to 1 liter per day." C. "Restrict your intake of potassium-rich foods." D. "Follow a low-sodium diet to reduce fluid overload."

Correct Answer is D

Explanation

A) This choice is incorrect because consuming a diet high in sodium would exacerbate fluid retention in congestive heart failure. Clients with CHF should follow a low-sodium diet to reduce fluid overload and manage edema.

B) This choice is incorrect because limiting fluid intake to 1 liter per day is too restrictive and may lead to dehydration. Fluid restriction is essential for some clients with CHF, but the specific limit should be determined by the healthcare provider based on the client's individual needs.

C) This choice is incorrect because while potassium intake may need to be monitored, restricting potassium-rich foods is not a universal instruction for clients with CHF. It depends on the client's overall potassium levels and specific medication regimen.

D) This choice is correct. Following a low-sodium diet is essential for clients with congestive heart failure to reduce fluid retention and manage symptoms of fluid overload.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with congestive heart failure. Which assessment finding may indicate a potential precipitating factor for the client's condition?

Correct Answer is D

Explanation

A nurse is providing education to a client with congestive heart failure regarding dietary management. Which instruction is essential for the nurse to include?

Correct Answer is D

Explanation

A nurse is providing education to a client with congestive heart failure about managing fluid intake. The nurse should instruct the client to:

A client with congestive heart failure complains of feeling fatigued and weak after mild physical activity, such as getting dressed or walking short distances. The nurse should identify this symptom as:

A client with congestive heart failure is prescribed spironolactone, a potassium-sparing diuretic. The nurse should instruct the client to:

A nurse is providing education to a client with congestive heart failure who is prescribed an angiotensin-converting enzyme (ACE) inhibitor. The nurse should instruct the client to:

A client with suspected congestive heart failure undergoes a chest X-ray. The nurse should anticipate which finding that may be indicative of CHF?

A client with congestive heart failure is prescribed a daily dose of furosemide. The nurse should monitor the client for which potential adverse effect of this medication?

A client with congestive heart failure is prescribed a beta-blocker. The nurse should closely monitor the client for which potential adverse effect of this medication?

A client with congestive heart failure is prescribed a loop diuretic. The nurse should closely monitor the client for which electrolyte imbalance associated with this medication?