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

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Hypothermia: Hypothermia can slow the heart rate, leading to bradycardia.

B. Calcium channel blockers medications: These medications can slow the conduction through the AV node, causing bradycardia.

C. Athletic conditioning: Athletes often have a lower resting heart rate due to increased parasympathetic tone, which can lead to sinus bradycardia.

D. Beta-blocker medications: Beta-blockers decrease heart rate by blocking the effects of adrenaline on the heart.

E. Hyperthyroidism: Hyperthyroidism usually leads to tachycardia, not bradycardia, due to increased metabolism.

A. A patient with second-degree atrioventricular (AV) block, type 1. rate 60, who is dizzy when ambulating B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due.

Correct Answer is D

Explanation

A. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating. While dizziness may be a concern, second-degree AV block type 1 (Wenckebach) typically resolves without immediate intervention.

B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago. This patient is stable, and recovery from cardioversion typically involves monitoring, but the patient does not require immediate intervention.

C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due. The patient is stable, and the dose of warfarin can be administered after assessing the patient’s overall condition, making it a lower priority.

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due: The patient whose ICD fired twice is at high risk for life-threatening arrhythmias, and this situation requires immediate evaluation and intervention. The nurse should assess the patient first, and the dose of amiodarone may be administered to manage any underlying arrhythmias.

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The nurse is assessing a client with decompensated heart failure. Which finding would indicate that the client is manifesting right-sided heart failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with sinus bradycardia. The nurse understands that this arrhythmia may be caused by which of the following? Select All That Apply

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is D

Explanation

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