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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tissue integrity: While assessing tissue integrity is important, ensuring airway patency takes precedence in the immediate postoperative period, especially following a procedure involving the larynx. Maintaining a patent airway is a critical priority.
B. Pain severity: Pain assessment is important, but it is not the primary concern immediately postoperatively in the context of a partial laryngectomy. Airway patency is of higher priority.
C. Airway patency: This is the correct answer. Following a partial laryngectomy, there may be concerns related to airway compromise due to the surgical procedure. The nurse should assess the airway first to ensure there are no obstructions or complications affecting the client's ability to breathe.
D. Wound drainage: While assessing wound drainage is important for monitoring surgical sites, it is not the first priority in the immediate postoperative period following a partial laryngectomy. Airway patency is a more critical concern.
Correct Answer is A
Explanation
A. Cellular hypoxia: Hemoglobin carries oxygen to the body's tissues. A low hemoglobin level, as well as a low hematocrit, indicates a reduced oxygen-carrying capacity of the blood, putting the client at risk for cellular hypoxia. Symptoms may include fatigue, weakness, and shortness of breath.
B. Prolonged bleeding: Hemoglobin and hematocrit levels are not directly indicative of a risk of prolonged bleeding. Prolonged bleeding is more related to platelet function and clotting factors.
C. Impaired immunity: Hemoglobin and hematocrit levels are not directly indicative of impaired immunity. Immune function is more closely associated with white blood cell count and function.
D. Fluid retention: Hemoglobin and hematocrit levels are not directly associated with fluid retention. Fluid retention is more related to factors such as sodium balance and kidney function.
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