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 D
Explanation
Choice A rationale
Palpating over the maxillary sinuses is not typically associated with oral cancer assessment. This action is more relevant to sinus issues and does not provide information about oral cancer.
Choice B rationale
Asking about a productive cough can be relevant in assessing respiratory conditions but is not a direct method for evaluating oral cancer. Oral cancer symptoms are more localized to the mouth area.
Choice C rationale
Observing for purulent nasal drainage is not a standard action in assessing for oral cancer. Nasal drainage would be more indicative of sinus or respiratory issues, not oral pathology.
Choice D rationale
Checking the mouth for leukoplakia is a key action when assessing for oral cancer. Leukoplakia presents as thickened, white patches inside the mouth and can be precancerous, making it a critical observation in potential oral cancer cases.
Correct Answer is A
Explanation
Choice A rationale
In prerenal AKI, the kidneys are not receiving enough blood flow. As a result, they cannot filter potassium out of the blood efficiently, leading to hyperkalemia, which is an elevated level of potassium in the blood. This condition is dangerous because it can cause cardiac dysrhythmias and muscle weakness.
Choice B rationale
Hypernatremia, an elevated sodium level, is not typically associated with prerenal AKI. It is more commonly related to dehydration or an excessive intake of sodium, which are not direct consequences of prerenal AKI.
Choice C rationale
Hypercalcemia, an elevated calcium level, is also not a common finding in prerenal AKI. It is usually associated with other conditions such as hyperparathyroidism or malignancy.
Choice D rationale
Hypophosphatemia, a low level of phosphate in the blood, is not a typical result of prerenal AKI. It can occur due to malnutrition or malabsorption, but it is not directly caused by prerenal AKI.
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