The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?
"How many pillows do you sleep on mister"
"Do you have chest pain when you walk up the steps?"
"Do you find that your rings and shoes feel tight at the end of the day?"
"How many times do you get up to void at night?"
The Correct Answer is A
A. This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B. Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C. Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D. Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.
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Related Questions
Correct Answer is C
Explanation
A. These are not typical symptoms of atrial flutter. They may be seen in other conditions like hypertensive crisis or systemic problems, but not as a primary manifestation of atrial flutter.
B. These are classic signs of diabetes or hyperglycemia, not atrial flutter.
C. These are common symptoms of atrial flutter, which results in an irregular heart rhythm and may cause increased heart rate, leading to palpitations and shortness of breath.
D. A systolic murmur is more associated with valve problems, and anxiety could be a result of various issues but is not a typical finding directly caused by atrial flutter.
Correct Answer is C
Explanation
A. “I probably will not have any transfusion reactions from my own blood.” - Autologous transfusions
generally have a lower risk of transfusion reactions because they involve the client’s own blood.
B. “This is the blood I’ve been giving for the past 6 weeks for myself.” - This is a correct understanding of the process of autologous blood donation, where the client donates blood for their own use.
C. An autologous blood transfusion involves the collection and storage of a patient's own blood for later transfusion. This significantly reduces the risk of bloodborne infections, such as hepatitis, HIV, and other blood-borne diseases, as the blood is coming from the patient themselves.
D. “Since I have O negative blood, it’s a good thing I’m getting my own blood.” - The client may not need additional teaching here because O negative blood is universally compatible, but the reason they are getting their own blood is due to the autologous donation process, not because of blood type.
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