When caring for the patient with left sided heart failure, which of the following are subjective symptoms?
Patient verbalizes frequent fatigue.
Elevated pulmonary capillary wedge pressure.
Orthopnea.
Cyanosis.
The Correct Answer is A
Choice A rationale
Fatigue is a subjective symptom because it is experienced and reported by the patient. Patients with left-sided heart failure often experience fatigue due to the heart’s inability to pump sufficient blood to meet the body’s needs.
Choice B rationale
Elevated pulmonary capillary wedge pressure is an objective symptom that can be measured and observed by healthcare professionals. It is not something that a patient can directly experience or report.
Choice C rationale
Orthopnea, or difficulty breathing when lying flat, is a subjective symptom as it is based on the patient’s personal experience. However, it is not the best answer in this case because the question asks for the “subjective symptoms,” and fatigue is a more common subjective symptom of left-sided heart failure.
Choice D rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective symptom that can be observed by healthcare professionals. It is not something that a patient can directly experience or report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
The RN must ensure that the nurse aide has the required training to perform these tasks. This is because the RN is responsible for determining client needs and when to delegate. The RN must also ensure that the delegate is competent to perform the activity.
Choice B rationale
The RN must maintain accountability for ensuring the delegated tasks are conducted correctly and completely. This is because the RN is answerable for their own choices, decisions, and actions as measured against a standard.
Choice C rationale
The RN must ensure policies cover the delegation. This is because the RN must understand the delegation process and the state nurse practice act (NPA) to ensure that it is safely, ethically, and effectively carried out.
Choice D rationale
The RN must perform an assessment of the patient prior to delegation. This is because the RN’s decision of whether or not to delegate is based upon their judgement concerning the condition of the patient.
Choice E rationale
While observing all tasks performed by the nurse aide II is a good practice, it is not a requirement for the RN in regard to this delegated task.
Correct Answer is B
Explanation
Choice A rationale
Only sterile objects should be placed on the sterile field. This is a correct practice and does not require intervention.
Choice B rationale
A sterile item with slightly opened packaging should not be placed on the sterile field. Any sign of damage or moisture is an indication that the package contents are no longer sterile.
Choice C rationale
A sterile object held below the nurse’s waist should be disposed of. This is a correct practice and does not require intervention.
Choice D rationale
The edges of the sterile field are considered contaminated. This is a correct practice and does not require intervention.
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