A nurse is assessing a patient who has right-sided heart failure. What findings should the nurse anticipate?
Orthopnea.
Pink frothy sputum.
Lower extremity edema.
Damp skin.
The Correct Answer is C
Choice A rationale
Orthopnea, or difficulty breathing when lying flat, is a common symptom of left-sided heart failure. It occurs due to fluid accumulation in the lungs, which makes it hard for the person to breathe when lying down.
Choice B rationale
Pink frothy sputum is a sign of pulmonary edema, a condition often associated with left-sided heart failure. It happens when fluid backs up into the lungs, causing shortness of breath and coughing up blood-tinged, frothy sputum.
Choice C rationale
Lower extremity edema is a common symptom of right-sided heart failure. It occurs due to fluid accumulation in the peripheral tissues, especially the legs and ankles, as a result of the heart’s inability to pump blood effectively.
Choice D rationale
Damp skin, or diaphoresis, is not specifically associated with right-sided heart failure. It can be a symptom of many conditions, including left-sided heart failure, where it is caused by the body’s increased effort to compensate for the heart’s decreased pumping ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Having a total cholesterol level below 200 mg/dL is generally considered healthy and does not increase stroke risk. High cholesterol can contribute to atherosclerosis, a condition that increases stroke risk.
Choice B rationale
Losing excess weight can indeed help decrease stroke risk. Obesity is a risk factor for several health conditions that increase stroke risk, including hypertension and diabetes.
Choice C rationale
Glucocorticoids are not typically prescribed to decrease stroke risk. In fact, long-term use of glucocorticoids can increase the risk of conditions such as hypertension and diabetes, which in turn can increase stroke risk.
Choice D rationale
An HbA1c level of 6 percent or less is generally considered good blood sugar control for people with diabetes. Good blood sugar control can help prevent complications of diabetes, including stroke.
Correct Answer is B
Explanation
Choice A rationale
Hypoactive bowel sounds in all four quadrants are not unusual in a patient one day postoperative following an appendectomy. This is because anesthesia and surgery can slow down the bowel movements temporarily.
Choice B rationale
Red streaks along the incision are a sign of infection. This could indicate cellulitis, a common skin infection that can be serious if left untreated. The red streaks are often warm to the touch and may be accompanied by other signs of infection such as fever, pain, and swelling.
Therefore, the nurse should report this finding.
Choice C rationale
Serosanguineous drainage at the incision site is not uncommon in the first few days after surgery. It is a mixture of blood and serum and is usually light pink to blood-tinged in color. However, if the drainage is heavy, or if it continues for more than a few days, it could be a sign of a problem such as infection or poor wound healing.
Choice D rationale
A temperature of 37.2 C (99 F) is within the normal range for body temperature. A slight elevation in temperature can be expected after surgery due to the body’s inflammatory response to the surgical trauma.
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