A nurse is assessing a client who has left-sided heart failure with diminished cardiac output. Which of the following findings should the nurse expect?
Weight gain
Warm extremities after walking
Breathlessness when carrying an object
Increased urinary output during the day
The Correct Answer is C
A) Weight gain: Weight gain is more commonly associated with right-sided heart failure due to fluid retention and peripheral edema. While left-sided heart failure can lead to overall heart failure, causing weight gain, it is not as specific as breathlessness for left-sided failure.
B) Warm extremities after walking: Warm extremities are generally a sign of good circulation. In clients with left-sided heart failure, reduced cardiac output often leads to poor peripheral circulation, which would more likely cause cool extremities.
C) Breathlessness when carrying an object: Left-sided heart failure leads to decreased cardiac output and pulmonary congestion. As a result, clients often experience breathlessness or dyspnea, especially during physical activities, because the heart cannot efficiently pump blood, leading to fluid buildup in the lungs.
D) Increased urinary output during the day: Left-sided heart failure usually causes decreased renal perfusion, leading to reduced urinary output during the day. Clients might experience nocturia (increased nighttime urination) due to fluid reabsorption when lying down, but increased daytime output is not typical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Muscle twitching:
Muscle twitching, also known as tetany, is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to symptoms such as muscle cramps, spasms, and twitching. This is a key clinical sign that helps in diagnosing hypocalcemia.
B) Bounding pulse:
A bounding pulse is not typically associated with hypocalcemia. Instead, it is more often seen in conditions such as fluid overload or hyperdynamic circulatory states, where there is increased cardiac output or vascular volume.
C) Hypertension:
Hypertension is not a common manifestation of hypocalcemia. Hypocalcemia is more likely to cause hypotension due to its effect on cardiac contractility and vascular tone, rather than causing high blood pressure.
D) Decreased bowel sounds:
Decreased bowel sounds are not commonly associated with hypocalcemia. Hypocalcemia affects neuromuscular function, but it typically causes increased gastrointestinal motility rather than decreased motility, which would lead to hyperactive bowel sounds rather than decreased ones.
Correct Answer is C
Explanation
A) Take a tub bath every other day using a mild soap: While maintaining hygiene is important, taking a tub bath is not the most effective way to prevent the spread of MRSA. Showering is usually recommended to help wash away bacteria without sitting in potentially contaminated water.
B) Wash bathroom surfaces daily with isopropyl alcohol: Cleaning surfaces regularly is important, but using isopropyl alcohol specifically for this purpose is not necessary. Household disinfectants that are effective against bacteria, including bleach solutions, can be used to disinfect surfaces.
C) Place the soiled dressing in a sealed plastic bag before placing it in the trash can: This instruction is crucial to prevent the spread of MRSA. Properly containing and disposing of contaminated dressings minimizes the risk of bacteria spreading to other surfaces or individuals.
D) Wash the wound area before washing the surrounding skin: When cleaning wounds, it's typically recommended to clean the surrounding skin first to avoid spreading bacteria from the wound to the clean skin. This reduces the risk of contamination and helps maintain a sterile environment around the wound.
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