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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Obtaining an ECG is important but not the first action. The priority is to stop activity, as exertion can worsen myocardial oxygen demand.
B. Having the client sit down immediately is correct. Stopping activity reduces cardiac workload and oxygen demand, preventing further ischemia or infarction.
C. Assessing vital signs is important but should follow stopping activity. Chest pain requires immediate action to reduce cardiac strain.
D. Administering sublingual nitroglycerin is appropriate but should be done after ensuring the client is seated. This prevents hypotension and syncope from occurring while standing.

A. Encourage an increased intake of the client's favorite drink B. Continue to monitor daily weights and edema and document findings. C. Perform a head-to-toe assessment, including vital signs D. Check the record to determine code status

Correct Answer is C

Explanation

A. Encouraging increased fluid intake is incorrect. Clients with heart failure are at risk for fluid overload, and excessive fluid intake can worsen symptoms.
B. Simply monitoring and documenting findings is insufficient. A 2-pound weight gain in a short period suggests fluid retention and worsening heart failure, requiring further assessment and possible intervention.
C. Performing a head-to-toe assessment, including vital signs, is correct. The nurse should assess for worsening heart failure, including lung sounds (crackles), respiratory effort, blood pressure, and oxygen saturation, to determine if immediate interventions are needed.
D. Checking code status is not the priority. While knowing a client’s code status is important, the immediate concern is assessing for signs of fluid overload and potential decompensation.

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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?

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