A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Orthopnea
Peripheral edema
Frothy sputum
Dyspnea
The Correct Answer is B
a. Orthopnea: Orthopnea is more commonly associated with left-sided heart failure, where fluid backs up into the lungs, making it difficult to breathe when lying down.
b. Peripheral edema: Right-sided heart failure can lead to systemic venous congestion, resulting in peripheral edema, often evident in the lower extremities.
c. Frothy sputum: Frothy sputum is more indicative of pulmonary edema, which is associated with left-sided heart failure.
d. Dyspnea: While dyspnea can occur with right-sided heart failure, it is more characteristic of left-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.
b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces
should not be present in the drainage appliance. This finding could indicate a complication and should be reported.
c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.
d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.
Correct Answer is C
Explanation
a. Hypoglycemia: Hypokalemia is not typically associated with hypoglycemia.
b. Hyperreflexia: Hypokalemia can lead to decreased reflexes, not hyperreflexia.
c. Cardiac dysrhythmias: Hypokalemia can cause disturbances in cardiac conduction, potentially leading to dysrhythmias.
d. Increased appetite: Increased appetite is not a common manifestation of hypokalemia.
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