The nurse is caring for a client with left-sided heart failure. Which of the following symptoms correlate to this diagnosis? (Select all that apply)
Tachypnea
Cough
Jugular vein distention
Ascites
Confusion
Correct Answer : A,B
Choice A reason: Tachypnea occurs in left-sided heart failure as pulmonary edema from backpressure increases respiratory effort to oxygenate blood through fluid-filled alveoli.
Choice B reason: Cough in left-sided failure results from pulmonary congestion irritating airways, often producing frothy sputum as fluid leaks from capillaries into lungs.
Choice C reason: Jugular vein distention indicates right-sided heart failure, where systemic venous pressure rises, not left-sided, which affects lungs, not neck veins.
Choice D reason: Ascites, abdominal fluid buildup, stems from right-sided failure’s hepatic congestion, not left-sided failure’s pulmonary focus, making it unrelated here.
Choice E reason: Confusion may occur late in severe heart failure from hypoxia, but it’s not specific to left-sided failure’s early pulmonary symptoms like tachypnea.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Working in undeveloped areas increases general infection risk, but hepatitis B specifically requires blood or fluid exposure, less likely without direct contact.
Choice B reason: Attending a conference poses low hepatitis B risk, as it’s not spread by casual contact, requiring blood or sexual transmission, not typical here.
Choice C reason: Assisting in birth involves fluid exposure, but two weeks is too short for hepatitis B symptoms; incubation is 45-180 days, so unlikely.
Choice D reason: Tattooing with unsterile needles risks hepatitis B via bloodborne transmission, matching the 90-day incubation period, the most likely risk here.
Correct Answer is A
Explanation
Choice A reason: Nasogastric suction removes gastric acid (HCl), reducing hydrogen ions, raising pH, and causing metabolic alkalosis, a common post-surgical complication here.
Choice B reason: Panic attacks cause respiratory alkalosis from hyperventilation, lowering CO2, not metabolic alkalosis, which involves base excess, unrelated to this ABG.
Choice C reason: ESRD typically causes metabolic acidosis from acid retention, not alkalosis, as kidneys fail to excrete hydrogen, opposing this patient’s ABG findings.
Choice D reason: Epidural catheters manage pain with analgesics, not affecting acid-base balance or causing metabolic alkalosis, irrelevant to the ABG shift observed.
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