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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hypoparathyroidism lowers PTH, reducing phosphorus excretion, raising serum levels as kidneys reabsorb more, while calcium drops, a classic imbalance.
Choice B reason: Calcium decreases in hypoparathyroidism due to low PTH, impairing bone resorption and gut absorption, opposite to being high, so this is incorrect.
Choice C reason: Magnesium isn’t directly regulated by PTH; hypoparathyroidism doesn’t consistently elevate it, staying normal unless other factors intervene.
Choice D reason: Potassium is unaffected by hypoparathyroidism, controlled by aldosterone and kidneys, not PTH, so it doesn’t rise with this condition.
Correct Answer is D
Explanation
Choice A reason: Increasing oxygen to 3 L/min may help but risks CO2 retention in COPD without assessing respiratory rate, depth, and saturation first, making it premature.
Choice B reason: Coughing clears secretions, but without assessing respiratory status, it’s unclear if secretions are the issue or if the client can effectively cough, so it’s not priority.
Choice C reason: Calling emergency services assumes severity without data like oxygen saturation or distress level, delaying care by skipping initial assessment in this stable setting.
Choice D reason: Assessing respiratory status (rate, oxygen saturation, lung sounds) identifies the cause of difficulty, guiding interventions like oxygen adjustment or escalation, per ABC priority.
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