A nurse is caring for a client who has right-sided heart failure. The nurse should assess the client for which of the following manifestations?

Decreased urinary output

Cool extremities

Peripheral edema

Crackles in the lung fields

Answer and Explanation

The Correct Answer is C

A. Decreased urinary output: Decreased urinary output can occur in heart failure due to reduced kidney perfusion, but it is more commonly associated with left-sided heart failure as it leads to fluid congestion in the lungs and a decreased ability of the kidneys to function effectively.

B. Cool extremities: Cool extremities can occur in heart failure, but they are more commonly seen in left-sided heart failure due to poor circulation from the left ventricle. Right-sided heart failure primarily affects the systemic circulation.

C. Peripheral edema: Peripheral edema is a hallmark sign of right-sided heart failure. The right side of the heart is unable to pump blood efficiently to the lungs, causing blood to back up into the veins and resulting in fluid retention in the lower extremities and other parts of the body.

D. Crackles in the lung fields: Crackles in the lung fields are a characteristic finding in left-sided heart failure, as fluid backs up into the lungs. This is not typically a finding associated with right-sided heart failure, which affects the systemic circulation.

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Correct Answer is D

Explanation

A. Increased joint pain: Joint pain is not a typical sign of overexposure to phototherapy. While psoriatic arthritis can occur in individuals with psoriasis, it is not directly linked to phototherapy overexposure.

B. Increased body temperature: While phototherapy may slightly raise the body's temperature, a significant increase in body temperature is not a typical indication of overexposure. This could suggest another underlying issue, such as infection or heatstroke.

C. Cool, moist extremities: Cool, moist extremities are not typically associated with phototherapy overexposure. This finding is more indicative of circulatory or other systemic issues, which do not directly result from phototherapy.

D. Small blisters on the skin: Small blisters on the skin are a common sign of overexposure to phototherapy. Phototherapy uses ultraviolet (UV) light, and excessive exposure can lead to skin damage, including burns or blisters, similar to sunburn.

A. Serous drainage noted in the collection chamber B. Tidaling in the water seal chamber with respirations C. Diminished breath sounds in the lung bases D. Movement of the trachea toward the unaffected side

Correct Answer is B

Explanation

A. Serous drainage noted in the collection chamber: The type of drainage typically seen with a pneumothorax is not serous; it is usually minimal or absent. If there is significant drainage, it could indicate bleeding or another issue that should be monitored.

B. Tidaling in the water seal chamber with respirations: Tidaling, or the movement of the water level in the water seal chamber with respirations, is a normal finding. It indicates that the chest tube is correctly placed, and the lung is expanding and contracting.

C. Diminished breath sounds in the lung bases: Diminished breath sounds are expected in the area where the pneumothorax occurred, but it does not specifically indicate the placement of the chest tube.

D. Movement of the trachea toward the unaffected side: Tracheal deviation toward the unaffected side is a sign of tension pneumothorax, which is a medical emergency. It should not be expected following the placement of a chest tube for a pneumothorax, as the goal of the chest tube is to resolve the pneumothorax and prevent complications.

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A nurse is caring for a client who has right-sided heart failure. The nurse should assess the client for which of the following manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving phototherapy for psoriasis. Which of the following findings should the nurse identify as an indication of overexposure?

Correct Answer is D

Explanation

A nurse is caring for a client following the placement of a chest tube drainage system for a pneumothorax. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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