A nurse is caring for a client in the outpatient cardiologist's office. The client is alert and oriented. Lung sounds with crackles are heard bilaterally. Dyspnea is observed on exertion, and heart sounds reveal an S3 gallop. Which of the following findings is the nurse most likely to expect?
Elevated blood pressure
Decreased respiratory rate
Pitting edema
Irregular pulse
The Correct Answer is C
Choice A rationale
Elevated blood pressure is a common finding in cardiovascular conditions but is not specifically indicated by the presence of crackles, dyspnea on exertion, or an S3 gallop.
Choice B rationale
A decreased respiratory rate is not typically associated with the presence of crackles and dyspnea; these symptoms are more indicative of increased work of breathing and potential fluid overload.
Choice C rationale
Pitting edema is a classic sign of fluid retention, which can be associated with heart failure. The presence of crackles, dyspnea on exertion, and an S3 gallop are clinical indicators that suggest heart failure, making pitting edema a likely finding.
Choice D rationale
An irregular pulse may be found in various cardiac conditions but is not directly suggested by the symptoms described. The presence of an S3 gallop is more indicative of heart failure, which is commonly associated with fluid overload signs such as pitting edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale
Chocolate is known to have moderate levels of potassium and should be limited in a diet for chronic kidney disease to prevent hyperkalemia¹.
Choice B rationale
Green beans are considered a lower potassium vegetable and can be included in a kidney-friendly diet in appropriate portions².
Choice C rationale
Tomatoes are high in potassium and should be avoided by individuals with chronic kidney disease to maintain safe potassium levels¹.
Choice D rationale
Bananas are very high in potassium and are one of the most well-known foods that individuals with chronic kidney disease are advised to avoid¹.
Choice E rationale
Asparagus is lower in potassium compared to other vegetables and can be consumed in moderation by people with chronic kidney disease².
Choice F rationale
Salt substitutes often contain potassium chloride and should be avoided as they can significantly increase potassium intake, which is harmful for those with chronic kidney disease¹.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Removing catheters as soon as they are no longer necessary can significantly reduce the risk of catheter-associated urinary tract infections (CAUTIs)¹.
Choice B rationale
While it is important for clients to urinate when they feel the urge, this practice alone is not specifically targeted at reducing the rate of urinary tract infections.
Choice C rationale
Teaching proper perineal care, including wiping from front to back, can help prevent the spread of bacteria to the urethra and reduce the risk of UTIs¹.
Choice D rationale
Continuing prescribed antibiotics until the full course is completed, even if symptoms improve, is crucial to ensure all bacteria are eliminated and to prevent antibiotic resistance³.
Choice E rationale
Adequate fluid intake helps flush bacteria from the urinary tract, which can decrease the incidence of UTIs¹.
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