A 72-year-old female has a history of right heart failure caused by a right ventricular myocardial infarction. Which of the following symptoms are specifically related to her right heart failure?
Hypertension
Dyspnea upon exertion
Significant edema to both lo
Decreased urine output
The Correct Answer is C
Choice A reason: This is not a symptom of right heart failure. Hypertension is a risk factor for developing heart failure, but it does not indicate the severity or location of the heart failure.
Choice B reason: This is not a symptom of right heart failure. Dyspnea upon exertion is a symptom of left heart failure, which occurs when the left ventricle fails to pump blood effectively to the lungs.
Choice C reason: This is a symptom of right heart failure. Significant edema to both lower legs and feet is a result of increased pressure in the systemic circulation, which occurs when the right ventricle fails to pump blood effectively to the rest of the body. This causes fluid to accumulate in the dependent areas, such as the lower extremities.
Choice D reason: This is not a symptom of right heart failure. Decreased urine output is a symptom of left heart failure, which occurs when the left ventricle fails to pump blood effectively to the aorta and the rest of the body. This causes reduced renal perfusion and oliguria.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Jugular vein distention is a sign of right-sided heart failure, not left-sided. It indicates increased pressure in the right atrium and vena cava.
Choice B reason: Peripheral edema is also a sign of right-sided heart failure, not left-sided. It indicates fluid retention in the lower extremities and abdomen.
Choice C reason: Decreased systemic vascular resistance is not a characteristic of left-sided heart failure. It is a compensatory mechanism that occurs in response to reduced cardiac output.
Choice D reason: Pulmonary congestion is a characteristic of left-sided heart failure. It indicates fluid accumulation in the lungs due to the inability of the left ventricle to pump blood effectively.
Correct Answer is A
Explanation
Choice A reason: Decrease in wheezing present on auscultation indicates that albuterol was effective. Albuterol is a bronchodilator that relaxes the smooth muscles of the airways and reduces the airway resistance. This improves the airflow and reduces the wheezing sound that is caused by the turbulent flow of air through the narrowed airways.
Choice B reason: Respiratory rate increased to 38 breaths/min does not indicate that albuterol was effective. It indicates that the patient is still experiencing respiratory distress and hypoxia. The normal respiratory rate for adults is 12 to 20 breaths/min. A high respiratory rate can also be a side effect of albuterol, as it can stimulate the sympathetic nervous system and increase the heart rate and blood pressure.
Choice C reason: Sputum production is clear and watery does not indicate that albuterol was effective. It indicates that the patient has a productive cough and is expelling mucus from the lungs. Sputum production is not directly affected by albuterol, as it does not have anti-inflammatory or mucolytic properties.
Choice D reason: Use of neck muscles does not indicate that albuterol was effective. It indicates that the patient is using accessory muscles to breathe and is exerting more effort to inhale. This is a sign of severe respiratory distress and airway obstruction. Albuterol should relieve the bronchospasm and reduce the need for accessory muscle use.
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