A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Increased pulmonary artery wedge pressure (PAWP).

Elevated central venous pressure (CVP).

Decreased brain natriuretic peptide (BNP).

Decreased specific gravity

Answer and Explanation

The Correct Answer is B

Right-sided heart failure is a condition in which the right ventricle fails to pump blood eﬀectively to the lungs, causing a backup of blood in the systemic circulation. This leads to increased pressure in the right atrium and the vena cava, which can be measured by the central venous pressure (CVP). A normal CVP is 2 to 6 mm Hg, but in right-sided heart failure, it can rise above 10 mm Hg. Symptoms of right-sided heart failure include peripheral edema, jugular venous distension, hepatomegaly, ascites, and weight gain.

a. Increased pulmonary artery wedge pressure (PAWP). This statement is incorrect because it describes a finding of left-sided heart failure, not right-sided heart failure. Left-sided heart failure is a condition in which the left ventricle fails to pump blood eﬀectively to the systemic circulation, causing a backup of blood in the pulmonary circulation. This leads to increased pressure in the left atrium and the pulmonary capillaries, which can be measured by the pulmonary artery wedge pressure (PAWP). A normal PAWP is 6 to 12 mm Hg, but in left-sided heart failure, it can rise above 18 mm Hg. Symptoms of left-sided heart failure include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles in the lungs, and pink frothy sputum.

c. Decreased brain natriuretic peptide (BNP). This statement is incorrect because it describes a finding of normal or reduced cardiac function, not heart failure. Brain natriuretic peptide (BNP) is a hormone secreted by the cardiac cells in response to increased stretch and pressure in the ventricles. It acts as a diuretic and a vasodilator, lowering blood volume and blood pressure. BNP is used as a biomarker for diagnosing and monitoring heart failure, as it reﬂects the degree of ventricular dysfunction. A normal BNP level is less than 100 pg/mL, but in heart failure, it can rise above 400 pg/mL.

d. Decreased specific gravity. This statement is incorrect because it describes a finding of dilute urine, not concentrated urine. Specific gravity is a measure of the concentration of solutes in urine, reﬂecting the ability of the kidneys to regulate ﬂuid balance. A normal specific gravity is 1.005 to 1.030, but it can vary depending on ﬂuid intake and output, hydration status, and renal function. In right-sided heart failure, ﬂuid retention and reduced renal perfusion can cause oliguria and increased specific gravity of urine.

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Correct Answer is ["50"]

Explanation

To calculate the gt/min, the nurse should use the following formula:

gt/min = (mL/hr x drop factor) / 60

Plugging in the given values, we get:

gt/min = (150 mL/hr x 20 gt/mL) / 60

gt/min = 3000 gt/hr / 60 gt/min = 50 gt/min

Therefore, the nurse should set the manual IV infusion to deliver 50 gt/min.

A. "You will notice a small hematoma at the incision site." B. "The dressing should be changed within 12 hours of the procedure." C. "You can resume regular exercise as soon as tomorrow." D. "Pain medication will not be necessary." E. None F. None

Correct Answer is A

Explanation

Rationale for A:

A small hematoma at the catheter insertion site is common after cardiac catheterization due to the puncture of blood vessels. The nurse should inform the client that this may occur but reassure them that it typically resolves on its own.

Rationale for B:

The dressing usually remains intact for 24 to 48 hours post-procedure to prevent infection and promote healing. The client should be instructed to keep the dressing clean and dry until the healthcare provider gives specific instructions.

Rationale for C: Clients are usually advised to avoid strenuous activities and exercise for several days after the procedure, not to resume regular exercise the next day.

Rationale for D: Pain medication may be necessary to manage discomfort post-procedure, and the nurse should encourage the client to take pain relief as needed.

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A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following an appendectomy and is prescribed 1 L lactated Ringer's at 150 mL/hr by continuous IV infusion for 12 hr. The drop factor of the manual IV tubing is 20 gt/mL. The nurse should set the manual IV infusion to deliver how many gt/min?

Correct Answer is ["50"]

Explanation

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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