A 65-year-old man presents to the clinic with complaints of swelling in his lower extremities, abdominal discomfort, and weight gain over the past few weeks. On examination, you notice jugular venous distention and hepatomegaly. Which condition is most likely causing these symptoms?

Left-sided heart failure

Right-sided heart failure

Liver cirrhosis

Chronic kidney disease

Answer and Explanation

The Correct Answer is B

Rationale:

A. Typically causes pulmonary symptoms, such as dyspnea, orthopnea, and pulmonary edema, rather than peripheral edema and hepatomegaly.

B. Right-sided HF leads to systemic venous congestion, causing peripheral edema, jugular venous distention, hepatomegaly, and abdominal discomfort. Weight gain from fluid retention is also common.

C. Can cause ascites and hepatomegaly, but usually accompanied by stigmata of chronic liver disease (jaundice, spider angiomas) and not jugular venous distention due to cardiac causes.

D. May cause generalized edema and weight gain, but jugular venous distention and hepatomegaly are less specific, and lab findings (BUN, creatinine) would help distinguish.

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Correct Answer is A

Explanation

Rationale:

A. This statement demonstrates that the client understands the importance of activity pacing and energy conservation, which is essential in managing congestive heart failure (CHF) to prevent overexertion and exacerbation of symptoms.

B. Clients with CHF should weigh themselves daily at the same time each day to detect early signs of fluid retention and worsening heart failure. Weekly monitoring is insufficient.

C. Sodium restriction is a critical part of CHF management because excess sodium contributes to fluid retention and worsening edema. This statement indicates a misunderstanding of dietary recommendations.

D. Diuretics are typically taken in the morning to prevent nocturia and sleep disruption. This statement reflects an incorrect understanding of medication timing.

A. Check for a pulse every 30 seconds B. Administer 1 mg of epinephrine C. Administer a defibrillation shock D. Begin chest compressions immediately

Correct Answer is D

Explanation

Rationale:

A. In a patient with asystole, a pulse check is not performed repeatedly in 30-second intervals; the rhythm is already pulseless, so delaying intervention to check the pulse wastes critical time.

B. Epinephrine is an important medication in asystole management, but it is administered after initiating CPR, not as the first step. Immediate medication without circulation is ineffective.

C. Defibrillation is ineffective in asystole because there is no organized electrical activity to reset. Defibrillation is reserved for shockable rhythms such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).

D. This is the correct initial step because asystole represents a complete absence of cardiac electrical activity, and immediate high-quality CPR is essential to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions increases the chance of survival while advanced life support measures (airway, epinephrine) are prepared.

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A 65-year-old man presents to the clinic with complaints of swelling in his lower extremities, abdominal discomfort, and weight gain over the past few weeks. On examination, you notice jugular venous distention and hepatomegaly. Which condition is most likely causing these symptoms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

Correct Answer is A

Explanation

Which of the following is the initial step in the management of a patient with asystole?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?

A nurse is caring for a client who has fluid volume excess (FVE) due to heart failure (HF). Which of the following manifestations should the nurse associate with FVE? (Select all that apply.)

A 55-year-old patient with a history of hypertension is undergoing a routine ECG as part of their annual check-up. The ECG reveals a first-degree AV block. Which of the following statements about first-degree AV block is correct?

A nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect?

A 65-year-old patient with congestive heart failure has been on diuretic therapy for the past two weeks. During a follow-up appointment, which of the following findings would indicate that the diuretic therapy is effective?

A patient taking spironolactone has a follow-up appointment. Which of the following laboratory values would be most important to monitor?

A nurse is teaching a client about the management of pericarditis. Which off the following client statements indicates to the nurse an understanding of the teaching?

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?