The nurse is assessing a newly admitted client diagnosed with left ventricular failure.
Which of the following findings should the nurse expect during the assessment?

Edema of the lower extremities.

Pulmonary crackles auscultated.

Ascites.

Jugular vein distention.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Edema of the lower extremities suggests right-sided heart failure, not left ventricular failure. Fluid backs up into systemic circulation in right-sided failure, while left-sided failure primarily affects pulmonary circulation. Differentiating between these conditions is essential for targeted management.

Choice B rationale

Pulmonary crackles result from fluid accumulation in alveoli due to left ventricular failure, where decreased cardiac output causes blood to back up into pulmonary vasculature. Crackles indicate pulmonary congestion or edema. Prompt identification aids in early intervention. Normal respiratory assessment excludes crackles.

Choice C rationale

Ascites is more indicative of chronic right-sided heart failure or liver disease, not acute left ventricular failure. Ascites results from systemic venous congestion, which is less common in isolated left-sided heart failure. Differentiating causes helps refine diagnostic focus.

Choice D rationale

Jugular vein distention is associated with elevated central venous pressure, typical of right-sided heart failure or combined heart failure. It does not specifically characterize left ventricular failure. Accurate recognition of findings ensures precise diagnosis and management.

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Correct Answer is D

Explanation

Choice A rationale

A low sodium, high-calorie diet does not directly address severe pain caused by renal colic. Dietary interventions are long-term strategies for kidney health but are not immediate priorities for acute pain relief. Renal colic pain requires prompt management with pharmacological interventions to alleviate severe discomfort. Adjusting dietary intake may support prevention but would not resolve the acute symptoms, emphasizing that this is not the first-line measure for this clinical situation.

Choice B rationale

Increasing fluid intake to 3–4 L/day is beneficial for flushing out kidney stones and preventing further stone formation. However, this intervention does not directly alleviate severe pain experienced during an episode of renal colic. While adequate hydration is crucial for long-term management, acute pain demands immediate pharmacological relief. Therefore, fluid intake implementation is secondary when compared to pain management priorities.

Choice C rationale

Tamsulosin (Flomax) is an alpha-blocker that promotes the passage of kidney stones by relaxing the smooth muscles of the ureter. Although effective in expediting stone passage, it does not provide immediate pain relief for severe renal colic. Its role is valuable for the resolution of the obstruction but does not address acute symptoms. Administering pain medication remains a priority to manage distress caused by colic episodes.

Choice D rationale

Morphine sulfate is an opioid analgesic that directly targets severe pain associated with renal colic. It binds to mu-opioid receptors in the central nervous system, producing analgesia and a calming effect. Its rapid onset and effectiveness in severe pain management make it the first prescription to implement. Pain relief improves the client's comfort and allows for addressing underlying causes of colic after stabilizing acute distress.

A. Magnesium and bilateral lower extremity ultrasounds. B. Urinalysis, blood chemistry, and 12-lead electrocardiogram. C. Complete blood count and electroencephalogram. D. Troponin, calcium, and partial thromboplastin time.

Correct Answer is B

Explanation

Choice A rationale

Magnesium levels and bilateral lower extremity ultrasounds are not specific for assessing target organ damage in hypertension. While magnesium may influence cardiovascular health, it is not a primary indicator of organ damage. Ultrasounds evaluate arterial or venous abnormalities, not hypertension’s systemic effects.

Choice B rationale

Urinalysis, blood chemistry, and a 12-lead electrocardiogram assess renal, metabolic, and cardiac effects of hypertension. Proteinuria in urinalysis indicates kidney damage. Electrolyte imbalances or creatinine elevations suggest renal impairment. An ECG reveals left ventricular hypertrophy or ischemia. These tests comprehensively evaluate hypertension-related complications.

Choice C rationale

A complete blood count evaluates blood cell counts but does not directly assess target organ damage from hypertension. An electroencephalogram assesses brain activity, not hypertension-induced injury. These tests are inappropriate for this diagnostic goal.

Choice D rationale

Troponin, calcium, and partial thromboplastin time evaluate myocardial infarction, bone health, and coagulation, respectively. They do not provide information about hypertension’s systemic organ effects. Accurate test selection ensures appropriate diagnostic focus.

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The nurse is assessing a newly admitted client diagnosed with left ventricular failure.Which of the following findings should the nurse expect during the assessment?

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Naxlex Comprehensive Predictor Exams

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Explanation

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The nurse is assessing a newly admitted client diagnosed with left ventricular failure.
Which of the following findings should the nurse expect during the assessment?