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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Increased pulmonary artery wedge pressure (PAWP). B. Elevated central venous pressure (CVP). C. Decreased brain natriuretic peptide (BNP). D. Decreased specific gravity

Correct Answer is B

Explanation

Right-sided heart failure is a condition in which the right ventricle fails to pump blood eﬀectively to the lungs, causing a backup of blood in the systemic circulation. This leads to increased pressure in the right atrium and the vena cava, which can be measured by the central venous pressure (CVP). A normal CVP is 2 to 6 mm Hg, but in right-sided heart failure, it can rise above 10 mm Hg. Symptoms of right-sided heart failure include peripheral edema, jugular venous distension, hepatomegaly, ascites, and weight gain.

a. Increased pulmonary artery wedge pressure (PAWP). This statement is incorrect because it describes a finding of left-sided heart failure, not right-sided heart failure. Left-sided heart failure is a condition in which the left ventricle fails to pump blood eﬀectively to the systemic circulation, causing a backup of blood in the pulmonary circulation. This leads to increased pressure in the left atrium and the pulmonary capillaries, which can be measured by the pulmonary artery wedge pressure (PAWP). A normal PAWP is 6 to 12 mm Hg, but in left-sided heart failure, it can rise above 18 mm Hg. Symptoms of left-sided heart failure include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles in the lungs, and pink frothy sputum.

c. Decreased brain natriuretic peptide (BNP). This statement is incorrect because it describes a finding of normal or reduced cardiac function, not heart failure. Brain natriuretic peptide (BNP) is a hormone secreted by the cardiac cells in response to increased stretch and pressure in the ventricles. It acts as a diuretic and a vasodilator, lowering blood volume and blood pressure. BNP is used as a biomarker for diagnosing and monitoring heart failure, as it reﬂects the degree of ventricular dysfunction. A normal BNP level is less than 100 pg/mL, but in heart failure, it can rise above 400 pg/mL.

d. Decreased specific gravity. This statement is incorrect because it describes a finding of dilute urine, not concentrated urine. Specific gravity is a measure of the concentration of solutes in urine, reﬂecting the ability of the kidneys to regulate ﬂuid balance. A normal specific gravity is 1.005 to 1.030, but it can vary depending on ﬂuid intake and output, hydration status, and renal function. In right-sided heart failure, ﬂuid retention and reduced renal perfusion can cause oliguria and increased specific gravity of urine.

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