A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

Weight gain

Anorexia

Distended abdomen

Breathlessness

Answer and Explanation

The Correct Answer is D

Choice A: Weight gain is not a manifestation of left-sided heart failure. Weight gain is more likely to occur in right-sided heart failure, as the blood backs up in the systemic circulation and causes ﬂuid retention and edema in the body.

Choice B: Anorexia is not a manifestation of left-sided heart failure. Anorexia is a loss of appetite, which can have many causes, such as psychological disorders, infections, medications, or cancer. Left-sided heart failure does not directly affect appetite, but it can cause nausea, fatigue, and weakness.

Choice C: A distended abdomen is not a manifestation of left-sided heart failure. A distended abdomen is more likely to occur in right-sided heart failure, as the blood backs up in the portal vein and causes increased pressure in the liver and spleen. This can lead to hepatomegaly, splenomegaly, ascites, and varices.

Choice D: Breathlessness is a manifestation of left-sided heart failure. Breathlessness, or dyspnea, is a sensation of difficulty breathing or shortness of breath. Breathlessness occurs in left-sided heart failure, as the blood backs up in the lungs and causes pulmonary congestion and edema. This impairs gas exchange and reduces oxygen delivery to the tissues.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because the carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is located on the side of the neck, near the trachea. The nurse should use two fingers to palpate the carotid pulse for at least 5 seconds and no more than 10 seconds.

Choice B Reason: This is incorrect because the popliteal pulse is located behind the knee and is not easily palpable during CPR.

Choice C Reason: This is incorrect because the radial pulse is located on the wrist and may not be detectable during CPR due to low blood pressure or peripheral vasoconstriction.

Choice D Reason: This is incorrect because the apical pulse is located on the chest and requires a stethoscope to auscultate. The nurse should not interrupt chest compressions or ventilations to listen to the apical pulse during CPR.

A. Clean the wound. B. Apply a tourniquet just below the elbow. C. Apply direct pressure over the wound. D. Elevate the limb and apply ice.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because cleaning the wound is not a priority when the client is bleeding profusely. Cleaning the wound can also dislodge any clots that have formed and increase bleeding.

Choice B Reason: This is incorrect because applying a tourniquet is a last resort when direct pressure fails to stop bleeding. A tourniquet can cause tissue damage, nerve injury, and infection if applied incorrectly or for too long.

Choice C Reason: This is correct because applying direct pressure over the wound is the first and most eﬀective action to stop bleeding from a wound. This is the first and most eﬀective action to stop bleeding from a wound. Direct pressure compresses the blood vessels and prevents further blood loss. The nurse should use a clean cloth or dressing to cover the wound and apply firm pressure with both hands.

Choice D Reason: This is incorrect because elevating the limb and applying ice are not eﬀective actions to stop bleeding from a wound. Elevating the limb can reduce blood ﬂow to the injured area, but it does not compress the blood vessels or prevent blood loss. Applying ice can cause vasoconstriction, but it can also damage the skin and tissues if applied for too long.

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A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

Nursing Test Bank

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Correct Answer is A

Explanation

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