The nurse is assessing a client with decompensated heart failure. Which finding would indicate that the client is manifesting right-sided heart failure?
Decreased peripheral pulses
S3 heart murmur
Distended neck veins
Orthopnea
The Correct Answer is C
A. Decreased peripheral pulses. Decreased pulses may be related to poor perfusion but are not a hallmark sign of right-sided heart failure.
B. S3 heart murmur. An S3 heart murmur is associated with left-sided heart failure due to fluid overload in the lungs.
C. Distended neck veins: Right-sided heart failure leads to the backup of blood in the systemic circulation, which often causes jugular vein distention (JVD), peripheral edema, and hepatomegaly.
D. Orthopnea. Orthopnea is a symptom of left-sided heart failure, where fluid builds up in the lungs, making it difficult to breathe when lying flat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client with left-sided heart failure on oxygen via nasal cannula: This client is at risk for respiratory distress due to pulmonary congestion. Immediate assessment is needed to ensure oxygenation and manage potential deterioration.
B. A client with syncope who is being discharged today: This client is stable if being discharged, so assessment can be delayed.
C. A client scheduled for a cardiac ultrasound this morning: This is a non-urgent diagnostic procedure and does not take priority.
D. A client with controlled atrial fibrillation with a heart rate of 82: Controlled atrial fibrillation indicates stability, so this client can be assessed later.
Correct Answer is C
Explanation
A. Decreased peripheral pulses. Decreased pulses may be related to poor perfusion but are not a hallmark sign of right-sided heart failure.
B. S3 heart murmur. An S3 heart murmur is associated with left-sided heart failure due to fluid overload in the lungs.
C. Distended neck veins: Right-sided heart failure leads to the backup of blood in the systemic circulation, which often causes jugular vein distention (JVD), peripheral edema, and hepatomegaly.
D. Orthopnea. Orthopnea is a symptom of left-sided heart failure, where fluid builds up in the lungs, making it difficult to breathe when lying flat.
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