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 ["A","B","C"]
Explanation
A. Reoccurrence of chest pain/discomfort: This can indicate restenosis or complications post-PCI, requiring immediate attention.
B. Puncture site for bleeding/hematoma: Bleeding at the puncture site is a common complication, so it must be closely monitored.
C. Pulse distal to puncture site: Checking the pulse distal to the puncture site helps assess for arterial occlusion or compromised blood flow, which can occur if a hematoma or clot forms.
D. Urinary output: While monitoring urinary output is important for overall assessment, it is not directly related to complications specific to PCI.
Correct Answer is A
Explanation
A. Hypertension: This is not a cause of high-output heart failure. Hypertension typically leads to low-output heart failure due to increased afterload, which causes the heart to work harder.
B. Severe anemia: Severe anemia causes high-output heart failure because the body compensates for the decreased oxygen-carrying capacity by increasing cardiac output.
C. Sepsis: Sepsis can lead to high-output heart failure as the body attempts to maintain perfusion in the face of widespread vasodilation.
D. Hyperthyroidism: Hyperthyroidism increases metabolic demands, which can cause high-output heart failure as the heart attempts to meet the increased needs.
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