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

Answer and Explanation

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.

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Correct Answer is B

Explanation

a. Low BP and low pulse rate: In hypovolemic shock, there is a decrease in blood volume,

leading to low blood pressure. However, the body compensates by increasing the heart rate to maintain perfusion to vital organs.

b. Low BP and high pulse rate: This is indicative of hypovolemic shock. The low blood pressure results from decreased blood volume, while the high pulse rate is a compensatory mechanism to maintain cardiac output.

c. High BP and low pulse rate: This combination is not typical of hypovolemic shock. High blood pressure is not expected in the presence of decreased blood volume.

d. High BP and high pulse rate: While a high pulse rate is expected in hypovolemic shock, high blood pressure is not a characteristic finding.

A. Three to seven days after menses stops. B. On the same day every month. C. Prior to the beginning of menses. D. On the second day of menstruation.

Correct Answer is A

Explanation

a. Three to seven days after menses stops: Performing BSE a few days after menstruation allows the breasts to return to a more baseline state, reducing the influence of hormonal changes on

breast tissue.

b. On the same day every month: Hormonal changes during the menstrual cycle can affect breast tissue, and performing BSE on the same day every month may not provide consistent conditions for examination.

c. Prior to the beginning of menses: Hormonal changes before menstruation can lead to breast tenderness and changes, potentially affecting the accuracy of the examination.

d. On the second day of menstruation: Hormonal changes and potential breast tenderness during the early days of menstruation may not be the optimal time for BSE.

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A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Explanation

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