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","C","D"]
Explanation
A. Apply pressure to the nares:
Applying gentle pressure to the nares can help control bleeding.
B. Tilt the client's head backward:
Tilt the head forward slightly to prevent blood from flowing down the back of the throat and to avoid swallowing blood.
C. Place ice to the bridge of the client's nose:
Cold packs can help constrict blood vessels and reduce bleeding.
D. Move the client into high-Fowler's position:
Sitting the client upright in a high-Fowler's position can minimize blood flow to the head and reduce bleeding.
E. Instruct the client to blow his nose:
Blowing the nose may disrupt clots and increase bleeding.
Correct Answer is B
Explanation
A. Respiratory alkalosis: Respiratory alkalosis is characterized by a decrease in carbonic acid (CO2) due to hyperventilation, leading to an increased pH. Shallow respirations would not typically cause respiratory alkalosis.
B. Respiratory acidosis: This is the correct answer. Shallow respirations result in inadequate elimination of CO2, leading to an excess of carbonic acid and the development of respiratory acidosis.
C. Metabolic acidosis: Metabolic acidosis is characterized by a decrease in bicarbonate (HCO3-), not carbonic acid (CO2). Shallow respirations would not directly contribute to metabolic acidosis.
D. Metabolic alkalosis: Metabolic alkalosis is characterized by an increase in bicarbonate (HCO3-). Shallow respirations would not typically cause metabolic alkalosis.
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