A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right- sided heart failure?
"My shoes fit really tight lately."
"I sleep with 2 pillows at night."
"I have trouble catching my breath."
"I wake up coughing every night."
The Correct Answer is A
A. Tight shoes may indicate fluid retention in the lower extremities, which is a common symptom of right-sided heart failure. This condition leads to the backup of blood into the systemic circulation, causing peripheral edema.
B. Sleeping with two pillows may indicate left-sided heart failure, as the client may be experiencing orthopnea (difficulty breathing when lying flat).
C. Shortness of breath is more commonly associated with left-sided heart failure.
D. Waking up coughing every night is also a sign of left-sided heart failure, where pulmonary congestion leads to nocturnal coughing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.
B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.
C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.
D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.
Correct Answer is C
Explanation
A. Defibrillation is used for life-threatening arrhythmias like ventricular fibrillation or pulseless ventricular tachycardia, not for SVT.
B. Cardioversion is appropriate for certain arrhythmias, but in this case, SVT with a stable pulse can be treated initially with medication like adenosine.
C. Adenosine is the first-line treatment for SVT. The typical starting dose is 6 mg IVP, which can be repeated if necessary. Adenosine works by temporarily blocking the electrical conduction through the AV node, allowing the heart to reset to a normal rhythm.
D. A 12 mg dose of Adenosine is used if the 6 mg dose is ineffective, but the 6 mg dose is typically administered first.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.