A nurse us collecting data from a client who has right sided heart faiulure. Which of the following should the nurse expect?
Crackles
Productive cough
Hepatomegaly
Dizziness
The Correct Answer is C
A. Crackles: Crackles in the lungs are a sign of left-sided heart failure, as fluid backs up into the pulmonary system.
B. Productive cough: A productive cough is also more commonly associated with left-sided heart failure, as it can result from fluid accumulation in the lungs.
C. Hepatomegaly: Hepatomegaly is a sign of right-sided heart failure, as blood backs up into the systemic circulation, leading to congestion in the liver.
D. Dizziness: Dizziness may occur in left-sided heart failure due to decreased cardiac output, but it is not a typical finding in right-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I’ll be sure to eat foods with lots of vitamin K." This statement shows misunderstanding, as vitamin K counteracts the effects of warfarin. The client should maintain a consistent intake of vitamin K, not increase it.
B. "I’ll use my electric razor for shaving." Using an electric razor reduces the risk of cuts, which could lead to bleeding, a common concern for clients on warfarin.
C. "It's okay to have a few glasses of wine every day." Alcohol can interfere with the metabolism of warfarin and increase the risk of bleeding. This is not a safe practice.
D. "I'll take aspirin for my headaches." Aspirin is an anticoagulant and can increase the risk of bleeding when taken with warfarin, so this statement indicates a lack of understanding.
Correct Answer is A
Explanation
A. "I will need to apply electrodes to your chest and extremities." This is a correct statement. The nurse needs to apply electrodes to the chest and extremities in order to obtain the ECG reading.
B. "You may feel a slight tingling while the test is being done." An ECG is a non-invasive test and does not cause any sensation such as tingling. This statement is inaccurate.
C. "The radioactivity from the dye lasts only a few hours." There is no dye or radioactivity involved in a standard ECG. This statement would apply to imaging studies like a nuclear stress test, not an ECG.
D. "The test will be complete in 30 to 60 minutes." A standard ECG takes only a few minutes to complete. This statement would be inaccurate for this type of procedure.
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