Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

Heart rate 100 beats per minute

+ 3 peripheral edema

Respiratory rate of 24 at rest

Alert and oriented X 3

Answer and Explanation

The Correct Answer is D

A.   A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B.   Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C.   A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D.   Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.

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Correct Answer is ["A","C","D"]

Explanation

A. Increased respiratory rate - Fluid overload can lead to pulmonary edema, which causes difficulty breathing and an increased respiratory rate.
B. Increased temperature - Fluid overload does not typically cause a temperature increase. A fever may indicate infection rather than fluid overload.
C. Increased heart rate - The body compensates for fluid overload by increasing the heart rate to maintain cardiac output.
D. Increased blood pressure - Fluid overload leads to increased blood volume, which results in elevated blood pressure.
E. Increase hematocrit - Hematocrit usually decreases with fluid overload, as it is diluted by the extra fluid volume.

A. Marked limitation with physical activity but comfortable at rest B. Angioedema and urticaria C. Increased urine output D. Chest pain during sleep that is relieved with nitroglycerin

Correct Answer is A

Explanation

A. Clients with left-sided heart failure often experience symptoms like shortness of breath, fatigue, and fluid retention, which limit physical activity. However, they may still feel relatively comfortable when resting.
B. These symptoms are more commonly associated with allergic reactions or side effects of medications (such as ACE inhibitors) rather than heart failure.
C. This is not typical in the later stages of left-sided heart failure. In fact, clients may experience reduced urine output due to poor kidney perfusion.
D. Chest pain can occur due to ischemia, but this is not a hallmark symptom of left-sided heart failure, which is more characterized by dyspnea and fatigue.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL
Calcium	8.0 mg/dL	8.2-10.2 mg/dL:

Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse is caring for a client who is in the later stages of left-sided heart failure. Which chief complaint would the nurse expect the client to report?

Correct Answer is A

Explanation

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