The nurse is caring for a client who has left-sided heart failure. Which statement made by the patient would be consistent with left-sided heart failure?

“The nurse I had yesterday told me that a vein in my neck was bulging."

"Both of my legs and feet are so swollen."

“I feel like fluid has been building up in my abdominal area."

"I have been coughing up pink, frothy sputum."

Answer and Explanation

The Correct Answer is D

A. Jugular vein distention (JVD) is more commonly associated with right-sided heart failure, not left-sided heart failure.
B. Peripheral edema is also more commonly associated with right-sided heart failure.
C. Ascites or fluid accumulation in the abdomen is typically associated with right-sided heart failure.
D. Pink, frothy sputum is indicative of pulmonary edema, which is a common symptom of left-sided heart failure due to the backup of blood into the lungs.

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Correct Answer is B

Explanation

A. While soft stools after taking docusate sodium is noteworthy, it is not immediately life-threatening and does not require urgent intervention.
B. Oliguria (low urine output) in a client with TTP is concerning because it may indicate acute kidney injury or worsening of the condition, requiring immediate assessment and intervention.
C. An elevated blood pressure in a client with PACs is important but not as critical as potential kidney dysfunction in the TTP patient.
D. A weight loss of 0.5 kg in a client with heart failure on furosemide may be expected and does not require immediate intervention.

A. Transfusion of platelets B. Replacement of ADAMTS-13 C. Administration of protamine sulfate D. Laparoscopic splenectomy

Correct Answer is D

Explanation

A. While a platelet transfusion can temporarily increase platelet counts, it does not reduce the destruction of platelets in ITP and is generally not effective as a long-term solution.
B. Replacement of ADAMTS-13 is relevant in thrombotic thrombocytopenic purpura (TTP), not ITP. It is not used for reducing platelet destruction in ITP.
C. Protamine sulfate is an antidote for heparin overdose and does not address the platelet destruction in ITP.
D. A laparoscopic splenectomy is often considered for clients with ITP who do not respond to medication therapy. The spleen is a primary site for platelet destruction, and its removal can reduce the destruction of platelets, leading to increased platelet counts.

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The nurse is caring for a client who has left-sided heart failure. Which statement made by the patient would be consistent with left-sided heart failure?

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Naxlex Comprehensive Predictor Exams

A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse place priority on assessing first?

Correct Answer is B

Explanation

A nurse is caring for a client who has a diagnosis of immune thrombocytopenic purpura (ITP). Despite medication therapy, the client's platelets are low. Which of the following procedures would reduce the destruction of platelets for a client who has ITP?

Correct Answer is D

Explanation

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