The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure?
Pallor and/or cyanosis of extremities
Orthopnea, peripheral edema, crackles
Dizziness, syncope. palpitations
PAWP of 12 and CVP of 6
The Correct Answer is B
A. Pallor and/or cyanosis of extremities: While pallor and cyanosis can indicate severe heart failure, they are not early signs. These symptoms usually appear later in the disease process.
B. Orthopnea, peripheral edema, crackles: These are early signs of heart failure indicating fluid overload due to decreased cardiac output. Orthopnea is difficulty breathing when lying flat, peripheral edema is swelling in the limbs, and crackles indicate fluid in the lungs.
C. Dizziness, syncope, palpitations:These symptoms can occur in heart failure but are not specific to fluid overload; they are more indicative of decreased cardiac output and possible arrhythmias.
D. PAWP of 12 and CVP of 6: These values are within normal limits. PAWP (Pulmonary Artery Wedge Pressure) and CVP (Central Venous Pressure) would be elevated in fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Patient stopped smoking five years prior to hospitalization: Smoking cessation materials are typically targeted to current smokers or those who have quit very recently (usually within the last year). This patient may not need smoking cessation materials as they have been smoke-free for a significant period.
B. Patient smokes five cigars a week: Smoking cigars still carries health risks similar to cigarettes and indicates the need for smoking cessation materials.
C. Patient uses chewing tobacco: Chewing tobacco is a form of smokeless tobacco, and while harmful, it would require different educational materials focused on smokeless tobacco cessation rather than smoking cessation.
D. Patient smoked cigarettes any time during the last year prior to hospitalization: This indicates current or recent smoking behavior which is a significant risk factor that needs to be addressed.
Correct Answer is ["B","E"]
Explanation
A. Annual vitamin K injections: Vitamin K injections do not prevent Hepatitis B.
B. Use of standard precautions: Standard precautions reduce the risk of exposure to bloodborne pathogens, including Hepatitis B.
C. Consumption of a vitamin-rich diet: While a healthy diet is important, it does not specifically prevent Hepatitis B.
D. Annual vitamin B12 injections: Vitamin B12 injections are unrelated to Hepatitis B prevention.
E. Immunization: Vaccination is a key preventive measure against Hepatitis B.
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