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 B

Explanation

A. Water pitcher on client's bedside table: Water does not require special handling after chemotherapy. The nurse should ensure that the client has access to clean drinking water, but there are no special precautions for handling it.
B. Client's urine in the bedside commode: Client's urine after chemotherapy requires special handling, as it may contain cytotoxic drugs or their metabolites for up to 48 hours. Proper precautions, such as wearing gloves and using appropriate disposal methods, are necessary to avoid exposure.
C. Client's bed linens after use: Bed linens do not require special handling unless contaminated with bodily fluids such as urine or vomit that could contain chemotherapy drugs. Gloves should be worn, but no additional precautions are required unless the linens are contaminated.
D. Food tray and utensils from client's breakfast: Food trays and utensils do not require special handling after chemotherapy unless they are contaminated with body fluids. Normal cleaning and sanitation practices are sufficient.

A. "I will have to work with a vocational counselor to find out what kinds of jobs I can do.” B. "I don't think I will ever be a whole person again." C. "I don't feel comfortable socializing with my friends." D. "My spouse and I both accept that I am no longer capable of taking care of myself."

Correct Answer is A

Explanation

A. This indicates that the client is actively working towards adapting to the changes in their life by exploring options for continuing work and adjusting to the new limitations. Seeking help from a vocational counselor is a positive sign of adjusting to role changes and maintaining a sense of purpose.

B. "I don't think I will ever be a whole person again.": This reflects feelings of hopelessness and a lack of acceptance of the amputation. It suggests that the client has not yet adapted to the role changes and may need further support in adjusting emotionally to the loss.

C. "I don't feel comfortable socializing with my friends.": This response indicates social withdrawal and discomfort, which may suggest difficulty adjusting to the changes in the client's life. It reflects emotional distress and lack of acceptance.

D. "My spouse and I both accept that I am no longer capable of taking care of myself.": While it is important to recognize the need for assistance, this statement indicates a defeatist attitude, implying a loss of independence that could hinder further adaptation.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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