A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?
Weight loss of 1 kg (2.2 lb) in the past 24 hr
Pale, clammy skin
Fatigue when ambulating 152 m (500 ft)
Productive cough with pink, frothy sputum
The Correct Answer is D
A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure.
It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation.
Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Iron supplementation commonly causes constipation, which is due to the iron's effect of slowing down bowel movements and increasing water absorption in the intestines.
Dry mouth is not a common adverse effect of iron supplementation. It is more commonly associated with medications that can cause xerostomia (dry mouth), such as certain antihistamines or anticholinergic drugs.
Tinnitus, a perception of ringing or noise in the ears, is not typically associated with iron supplementation. Tinnitus can be caused by various factors, such as exposure to loud noises, ear infections, or certain medications, but it is not directly related to iron supplementation.
Hematuria, the presence of blood in the urine, is not a common adverse effect of iron supplementation. It can be caused by various conditions affecting the urinary system, such as urinary tract infections, kidney stones, or bladder issues, but it is not directly related to iron supplementation.
Correct Answer is A
Explanation
Giving change-of-shift report to a nurse outside the client's room helps to maintain client confidentiality. By discussing sensitive client information in a private and secure area, such as a designated report room or a location where other clients or visitors cannot overhear, the nurse ensures that the client's personal and medical information is not disclosed to unauthorized individuals.
Writing a client's diagnosis on the message board in the client's room can potentially expose sensitive medical information to anyone who enters the room, including visitors or other healthcare providers who are not directly involved in the client's care.
Discussing a client's prognosis with an assistive personnel who is caring for the client may violate the principle of need-to-know confidentiality. While it is important for healthcare team members to collaborate and communicate about client care, sensitive information should only be shared on a need-to-know basis.
Discarding worksheets containing client information in a wastebasket without proper shredding or disposal methods can potentially expose client information to unauthorized individuals who may come across the discarded documents. Proper procedures for document disposal, such as shredding or using secure disposal containers, should be followed to protect client confidentiality.
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