A nurse is caring for an older adult who has left-sided heart failure.
Which of the following assessment findings should the nurse expect?
Pulmonary crackles.
Jugular vein distension.
Dependent edema.
Nocturnal polyuria.
The Correct Answer is A
Choice A rationale
Left-sided heart failure impairs the left ventricle's ability to effectively pump oxygenated blood forward into the systemic circulation. This causes blood to back up into the left atrium and subsequently into the pulmonary veins and capillaries, resulting in increased pulmonary pressure. Fluid then leaks into the alveoli, causing the classic sound of pulmonary crackles (rales).
Choice B rationale
Jugular vein distension (JVD) is a cardinal sign of increased pressure in the systemic venous circulation, indicating right-sided heart failure. When the right ventricle fails, blood backs up into the right atrium and then into the great veins, causing distension and visibility of the internal and external jugular veins in the neck.
Choice C rationale
Dependent edema, which is swelling in the lower extremities, is a typical manifestation of right-sided heart failure. The inability of the right ventricle to manage systemic venous return causes blood to pool in the peripheral veins, leading to increased hydrostatic pressure that forces fluid out of the capillaries into the interstitial tissue.
Choice D rationale
Nocturnal polyuria, or increased urination at night, is a common symptom in heart failure but is more directly related to the movement of pooled dependent edema fluid (from the legs/feet) back into the central circulation when the client lies down. This increases renal blood flow and diuresis, but is not exclusively an assessment finding for left-sided failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While a pregnancy test is important in a sexually active woman presenting with urinary symptoms to rule out ectopic pregnancy or potential teratogenic antibiotic exposure, the initial step must be to gather comprehensive data. A pregnancy test is a diagnostic tool, and its necessity follows the initial data collection for context.
Choice B rationale
A thorough history and physical examination is the fundamental first step in evaluating any patient, regardless of the chief complaint. This process allows the healthcare provider to gather subjective and objective data, assess risk factors, narrow the differential diagnosis for the dysuria, hematuria, and frequency, and guide appropriate diagnostic testing, such as a urine sample.
Choice C rationale
A urine culture is a specific diagnostic test used to identify the causative organism in a suspected urinary tract infection. Although a urine sample collection will likely follow the initial assessment, ordering the culture before a thorough history and physical is premature and does not follow the standard, systematic approach to patient care.
Choice D rationale
Starting empiric antibiotics without a thorough assessment and potential diagnostic confirmation is poor medical practice. Although the symptoms strongly suggest a urinary tract infection, a course of antibiotics should only be initiated after a history and physical and, ideally, after obtaining a urine sample for testing to ensure appropriate, targeted therapy. —.
Correct Answer is ["4"]
Explanation
Step 1 is to use the concentration available to calculate the volume (mL) needed to administer the ordered dose (mg). Volume (mL) = Dose ordered (mg) ÷ Concentration available (mg/mL).
Step 2 is to first determine the concentration available in mg/mL. 400 mg ÷ 5 mL = 80 mg/mL.
Step 3 is to calculate the volume to administer per dose. 320 mg ÷ 80 mg/mL = 4 mL. The nurse should administer 4.0 mL per dose. .
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