The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Edema

Shortness of breath

Increase in appetite

Extreme weight loss

Jugular vein distended (enlarged)

Answer and Explanation

Correct Answer : A,B,E

A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.

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Correct Answer is A

Explanation

A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.

A. "I would palpate, inspect, percuss, and the auscultate.” B. "I would percuss, palpate, auscultate, and then inspect.” C. "I would auscultate, inspect, percuss, and then palpate." D. "I would inspect, auscultate, palpate, and then percuss." E. "I would inspect, palpate, percuss, then auscultate.”

Correct Answer is E

Explanation

A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.

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The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is E

Explanation

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