The nurse is assessing a client with the diagnosis of left-sided heart failure. Which clinical finding should the nurse expect the client to experience?
Orthopnea
Bradycardia
Diaphoresis
Frequent coughing with yellow sputum
The Correct Answer is A
A. Orthopnea is correct. Left-sided heart failure causes pulmonary congestion, making it difficult for the client to breathe when lying flat. This results in orthopnea, where the client must sit up or use multiple pillows to breathe comfortably.
B. Bradycardia is incorrect. Heart failure typically leads to tachycardia due to the heart compensating for decreased cardiac output.
C. Diaphoresis is incorrect. While excessive sweating can occur in acute decompensated heart failure, it is not a hallmark symptom of left-sided heart failure.
D. Frequent coughing with yellow sputum is incorrect. A client with left-sided heart failure may have a dry or frothy, pink-tinged cough, but yellow sputum suggests infection rather than heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Crossing the legs can actually increase the risk of venous stasis and clot formation, which can lead to a pulmonary embolism. The client needs further teaching to avoid this habit.
B. Smoking increases the risk of blood clot formation, so quitting smoking is an appropriate preventive measure.
C. Staying hydrated helps maintain good blood flow and reduces the risk of clot formation.
D. Regular exercise and weight management help prevent venous stasis and clot formation, lowering the risk of pulmonary embolism.
Correct Answer is B
Explanation
A. Nitroglycerin is used in the acute phase of an MI to relieve chest pain by dilating coronary arteries. However, after the initial phase, it is not the primary medication for managing pain and anxiety.
B. Morphine is administered after the initial acute phase to manage pain and anxiety. It reduces myocardial oxygen demand, decreases pain perception, and provides sedation, which can help lower stress levels.
C. Aspirin is given in the acute phase to prevent further clot formation but does not address pain and anxiety.
D. Oxygen is administered in the acute phase if the client is hypoxic, but routine oxygen therapy is no longer recommended unless needed.
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