The nurse is assessing a client with right-sided heart failure. Which of the following findings should the nurse expect? Select all that apply.
Distended jugular veins
Weight gain
Orthopnea
Peripheral edema
Crackles the lungs
Correct Answer : A,B,D
A. Distended jugular veins: Right-sided failure increases pressure in the right atrium and vena cava, leading to visible engorgement of the internal jugular veins. This finding reflects the retrograde backup of blood into the systemic venous system. It is a primary clinical indicator of elevated central venous pressure.
B. Weight gain: Rapid increase in body mass in heart failure patients is almost exclusively due to the retention of sodium and water. As the kidneys perceive low perfusion, the renin-angiotensin-aldosterone system triggers fluid volume expansion. This leads to the systemic accumulation of fluid characteristic of right-sided dysfunction.
C. Orthopnea: This symptom involves difficulty breathing while lying flat and is a classic sign of left-sided heart failure and pulmonary congestion. It occurs when fluid from the lower extremities redistributes to the lungs in a recumbent position. Right-sided failure alone does not typically cause this pulmonary-specific symptom.
D. Peripheral edema: Increased systemic venous pressure causes fluid to leak from the capillaries into the interstitial spaces of the lower extremities. This presents as swelling in the feet, ankles, and pretibial areas, often worsening as the day progresses. It is a hallmark sign of right-heart pump failure.
E. Crackles the lungs: Adventitious lung sounds like crackles indicate fluid in the alveoli, which is a manifestation of pulmonary edema. Pulmonary edema is caused by the failure of the left ventricle to move blood into the systemic circulation. It is not a direct finding of isolated right-sided heart failure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Nitroglycerin: This vasodilator is used to treat anginal chest pain by reducing preload and dilating coronary arteries. It has no role in the management of atrial fibrillation, which is characterized by an irregularly irregular rhythm. Using a nitrate here would not address the underlying electrical disorganized activity in the atria.
B. Hydrochlorothiazide: As a thiazide diuretic, this medication is used primarily for the long-term management of hypertension and mild fluid retention. It does not possess any antiarrhythmic properties and would not be effective in controlling the ventricular rate. Diuretics are not the standard of care for treating an acute rhythm disturbance on a telemetry strip.
C. Atropine: This anticholinergic agent is indicated for the treatment of symptomatic bradycardia by increasing the heart rate. Atrial fibrillation often requires rate control to prevent tachycardia-induced cardiomyopathy rather than stimulation of a faster rate. Atropine could potentially worsen the clinical situation by causing a dangerously rapid ventricular response.
D. Warfarin: Atrial fibrillation causes blood to pool in the atria, which significantly increases the risk of mural thrombus formation and subsequent embolic stroke. Anticoagulation is a mandatory component of management to prevent these life-altering thromboembolic complications. Warfarin is a standard oral anticoagulant used to maintain a therapeutic INR in patients with this chronic dysrhythmia.
Correct Answer is B
Explanation
A. Encourage the client to drink fluids and then give the medication: While increasing fluid intake can help raise blood pressure if the cause is dehydration, it does not justify giving an antihypertensive to a hypotensive patient. Administering lisinopril will further lower the pressure regardless of fluid status. The priority is to avoid exacerbating the existing hypotension.
B. Hold the dose and notify the healthcare provider: A blood pressure of 88/56 is significantly below the normal therapeutic range and indicates that the patient cannot tolerate further antihypertensive therapy. Giving the lisinopril could lead to profound hypotension, syncope, or decreased organ perfusion. The nurse must withhold the drug and seek medical guidance for dose adjustment.
C. Give half the dose and recheck the blood pressure in 30 minutes: Nurses are not authorized to alter the prescribed dose of a medication or provide a partial dose without a specific physician order. Even a half-dose of an ACE inhibitor could be dangerous for a client whose pressure is already below 90 mmHg systolic. Clinical judgment requires stopping the medication entirely until the patient is stable.
D. Document the finding and give the drug as usual: Giving the drug as usual despite a blood pressure of 88/56 is a medication error that ignores critical assessment data. This action directly endangers the patient and violates basic safety protocols for administering cardiovascular medications. Documentation of the vital signs must be followed by an appropriate clinical action, which is withholding the dose.
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