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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This choice is incorrect because bradycardia (slow heart rate) is not a common adverse effect of furosemide, a loop diuretic.
B) This choice is correct. Furosemide is a loop diuretic that can lead to increased potassium excretion in the urine, potentially causing hypokalemia (low potassium levels). The nurse should closely monitor the client's potassium levels and provide potassium supplementation if necessary.
C) This choice is incorrect because hypertension (high blood pressure) is not typically associated with loop diuretics like furosemide. In fact, furosemide is used to treat hypertension and congestive heart failure by promoting the excretion of excess fluid and reducing blood pressure.
D) This choice is incorrect because hyperglycemia (high blood glucose levels) is not a common adverse effect of furosemide. In fact, furosemide can sometimes cause transient hypoglycemia.
Correct Answer is C
Explanation
A) This choice is incorrect because bradycardia (slow heart rate) is not a common adverse effect of furosemide, a loop diuretic.
B) This choice is incorrect because hyperglycemia (high blood glucose levels) is not a common adverse effect of furosemide. In fact, furosemide can sometimes cause transient hypoglycemia.
C) This choice is correct. Hypotension (low blood pressure) is a potential adverse effect of furosemide due to its diuretic action. Furosemide causes the excretion of excess fluid, leading to a decrease in blood volume, which can result in hypotension.
D) This choice is incorrect because a dry, nonproductive cough is associated with ACE inhibitors, not furosemide.
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