A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?
Dependent edema
Frothy sputum
Nocturnal polyuria
Jugular distention
The Correct Answer is B
Frothy sputum is a sign of left-sided heart failure, due to the pulmonary congestion and impaired gas exchange. The sputum may be pink-tinged or blood-streaked, indicating pulmonary edema.
a. Dependent edema is more likely to be seen in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
c. Nocturnal polyuria is not a specific finding of left-sided heart failure, but it may occur in clients who have renal impairment, diabetes mellitus, or diuretic therapy.
d. Jugular distention is another sign of right-sided heart failure, due to the increased central venous pressure and backward flow of blood into the superior vena cava. It is visible as a bulging of the neck veins, especially when the client is in a semi-Fowler's position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B
Choice B reason: Intermittent claudication
Intermittent claudication is a characteristic symptom of PAD in the early stage, due to the reduced blood flow to the muscles during exercise. It is a cramping pain in the legs that occurs with walking and is relieved by rest.
Choice A reason: Dependent rubor is a sign of PAD in the advanced stage, due to the impaired vasodilation and reactive hyperemia. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
Choice C reason: Foot ulcers are a complication of PAD in the late stage, due to the poor wound healing and tissue necrosis. They are usually located on the toes, heels, or pressure points.
Choice D reason: Rest pain is another sign of PAD in the late stage, due to the severe ischemia and nerve damage. It is a persistent pain in the feet or toes that occurs at night and is not relieved by rest.
Correct Answer is C
Explanation
Swallowing the capsules whole is the correct way to take nitroglycerin oral, sustained-release capsules, as they are designed to release the medication slowly and steadily over time. The client should not crush, chew, or open the capsules, as this can alter the absorption and effectiveness of the medication.
Taking 1 capsule at the onset of anginal pain is not appropriate, as nitroglycerin oral, sustained-release capsules are not meant for acute episodes of angina, but for long-term prevention and management. The client should use a fast-acting form of nitroglycerin, such as sublingual tablets or spray, to relieve anginal pain.
Taking the medication with meals is not necessary, as nitroglycerin oral, sustained-release capsules can be taken with or without food. However, the client should take the medication at regular intervals and around the same time each day.
Stopping taking the medication if side effects are troublesome is not advisable, as nitroglycerin oral, sustained-release capsules can cause withdrawal symptoms and rebound angina if discontinued abruptly. The client should consult with the provider before stopping or changing the dose of the medication. The client should also report any severe or persistent side effects, such as headache, dizziness, hypotension, or tachycardia.
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