A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Hacking cough
Abdominal distension
Dependent edema
Jugular venous distention
The Correct Answer is A
A. Hacking cough: This is the correct answer. Left-sided heart failure can lead to pulmonary congestion, resulting in a cough that is often described as "hacking" or "persistent." This cough may be worse at night when the client is lying down.
B. Abdominal distension: Abdominal distension is more commonly associated with right-sided heart failure, as fluid accumulates in the abdomen (ascites). In left-sided heart failure, fluid accumulates in the lungs, leading to pulmonary symptoms.
C. Dependent edema: Dependent edema is also more commonly associated with right-sided heart failure. In left-sided heart failure, fluid tends to accumulate in the lungs, causing pulmonary congestion and related symptoms.
D. Jugular venous distention: Jugular venous distention is often seen in right-sided heart failure due to impaired blood flow from the right atrium into the right ventricle. This finding is less likely to be prominent in left-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It requires lying quietly on one side": This is the correct answer. During an echocardiogram, the client is typically asked to lie on their left side to obtain clear images of the heart. The test is non-invasive and involves using ultrasound waves to create images of the heart's structures.
B. "It might cause slight discomfort in the chest area": Echocardiograms are generally painless and do not cause discomfort. They are a non-invasive imaging technique that uses sound waves.
C. "It is best to have no food or beverages the day of the test": While the client may be instructed to avoid eating or drinking shortly before the test, this statement is too restrictive. The specific fasting instructions will be provided by the healthcare provider or facility.
D. "It takes about 5 or 10 minutes": The duration of an echocardiogram can vary, but it typically takes longer than 5 or 10 minutes. The test duration depends on various factors, including the complexity of the study and the information needed.
Correct Answer is B
Explanation
A. "The medication can take up to 15 minutes to take effect." - This statement is not accurate, sublingual nitroglycerin works rapidly and often provides relief within a few minutes.
B. Sublingual nitroglycerin is administered by placing the tablet under the tongue, and it should be allowed to dissolve or be absorbed directly into the bloodstream through the mucous membranes. It is not swallowed or chewed. The small sip of water can help facilitate the dissolving process.
C. "Avoid taking the medication prior to exercising." - This statement is not accurate. Nitroglycerin can be taken before anticipated exertion or activities that may trigger angina to prevent anginal episodes during physical activity.
D. "Stop taking the medication and notify your provider if you develop a headache." - While headaches are a common side effect of nitroglycerin, they are generally transient and not a reason to stop taking the medication. Persistent or severe headaches should be reported to the healthcare provider.
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