The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

Jugular vein distention.

Bilateral basilar crackles.

3+ pitting enema in the ankles.

Hepatomegaly with right upper quadrant (RUQ) tenderness.

Answer and Explanation

The Correct Answer is B

Choice A reason: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.

Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.

Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.

Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.

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Free Nursing Study Resources

Correct Answer is ["0.4"]

Explanation

Step 1: Determine the concentration of enoxaparin. 60 mg is equivalent to 0.6 mall

Step 2: Set up the ratio to find how many mL corresponds to 40 mg. (40 mg) ÷ (60 mg) = x ÷ (0.6 mL)

Step 3: Solve for x. x = (40 mg) × (0.6 mL) ÷ (60 mg) x = 24 ÷ 60 x = 0.4 mL

So, the nurse should administer 0.4 mL

A. A haemoglobin of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction). B. Vital signs are temperature 99.0°F (37.2°C) orally, heart rate 94 beats/minute, respirations 18 breaths/minute, blood pressure 110/70 mm Hg. C. Vomits coffee-grounds emesis. D. Reports having sharp epigastric pain.

Correct Answer is C

Explanation

Choice A reason: A haemoglobin level of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction) are slightly lower than the reference range but not critically low. This finding is important and needs to be monitored, but it does not require the most immediate intervention.

Choice B reason: The vital signs provided are within normal limits and do not indicate an urgent or life-threatening condition. These should be monitored, but they do not require immediate intervention compared to other findings.

Choice C reason: Vomiting coffee-grounds emesis is a sign of gastrointestinal bleeding, specifically indicating that blood has been in the stomach long enough to be partially digested by stomach acid, giving it a coffee-grounds appearance. This is a serious and potentially life-threatening condition requiring immediate medical intervention to stop the bleeding and prevent further complications.

Choice D reason: Sharp epigastric pain is a common symptom of peptic ulcer disease and indicates inflammation or ulceration. While it is painful and concerning, it does not require the most immediate intervention compared to active gastrointestinal bleeding.

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The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a prescription for enoxaparin 40 mg subcutaneous (sub) daily. Enoxaparin is available in a pre-filled cartridge labelled, "60 mg per 0.6 mall" How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.4"]

Explanation

A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?

Correct Answer is C

Explanation

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