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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light
B.Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C.Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
Correct Answer is C
Explanation
Leukorrhea refers to the increased vaginal discharge that is common during pregnancy. It is usually thin, white, or milky in appearance and is caused by hormonal changes and increased blood flow to the vaginal area. Informing the client about this normal pregnancy symptom can help alleviate concerns and promote reassurance.
Facial swelling, especially during the first trimester, is not a common discomfort experienced in early pregnancy. It can be a symptom of other underlying medical conditions, such as preeclampsia, which should be evaluated by a healthcare provider.
While gastrointestinal changes and bowel irregularities can occur during pregnancy, including constipation, diarrhea is not typically associated with the first trimester. Persistent or severe diarrhea should be assessed by a healthcare provider as it can indicate an underlying issue or infection.
Burning or discomfort during urination is not a typical discomfort of the first trimester. It is more commonly associated with urinary tract infections (UTIs) or other urinary issues. If a client experiences these symptoms, they should be evaluated by a healthcare provider for appropriate diagnosis and treatment.
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