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 C

Explanation

A. Heart rate of 134 bpm. A heart rate of 134 bpm is expected during a cardiac stress test, as the goal is to increase the heart rate to a target range to evaluate cardiac function under stress.

B. Mild shortness of breath. Mild shortness of breath is a common response to exercise and is not an indication to stop the test unless it becomes severe or is accompanied by other concerning symptoms like chest pain or cyanosis.

C. Three premature ventricular contractions in a row indicate a potential serious arrhythmia (ventricular tachycardia), which is a contraindication for continuing the stress test. This finding could place the client at risk for life-threatening cardiac events, such as ventricular fibrillation.

D. Blood pressure 152/88 mmHg. This is a slightly elevated but normal physiological response to exercise and does not warrant discontinuation of the test unless the blood pressure rises to dangerously high levels (e.g., >200/110 mmHg).

A. Apply warm compresses to site of the client's pacemaker insertion B. Teach the client to avoid being near any type of household microwave oven C. Ambulate the client as soon as possible to evaluate function of pacemaker. D. Instruct client to limit movement of arm on side where pacemaker inserted.

Correct Answer is D

Explanation

A. Apply warm compresses to site of the client's pacemaker insertion: Heat application is contraindicated as it may increase swelling or risk infection.

B. Teach the client to avoid being near any type of household microwave oven: Modern pacemakers are shielded, so microwaves do not interfere with their function.

C. Ambulate the client as soon as possible to evaluate pacemaker function: While early ambulation is encouraged, pacemaker function is not evaluated through ambulation.

D. Instruct client to limit movement of the arm on side where pacemaker was inserted: Limiting arm movement prevents dislodging the pacemaker leads during the healing phase.

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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?

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