A nurse is assessing a client who has right-sided heart failure.

Which of the following assessment findings should the nurse expect to find?

Poor skin turgor.

Pitting edema.

Oliguria.

S4 galloping heart sounds.

Answer and Explanation

The Correct Answer is B

Pitting edema is a common and obvious symptom of right-sided heart failure.

This occurs when fluid retention causes swelling in the lower limbs and sometimes the abdomen.
Choice A is incorrect because poor skin turgor is not a common symptom of right-sided heart failure.
Choice C is incorrect because oliguria, or decreased urine output, is not a common symptom of right-sided heart failure.
Choice D is incorrect because S4 galloping heart sounds are not a common symptom of right-sided heart failure.

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Correct Answer is C

Explanation

The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.

A. Acupuncture. B. Saw palmetto. C. Colonics. D. Guided imagery.

Correct Answer is C

Explanation

Colonics, also known as colonic irrigation or colon hydrotherapy, involves flushing the colon with fluids to remove waste and is not recommended for individuals with diverticulitis.
Choice A is wrong because acupuncture is not a contraindication for a client with diverticulitis.
Choice B is wrong because saw palmetto is not a contraindication for a client with diverticulitis.
Choice D is wrong because guided imagery is not a contraindication for a client with diverticulitis.

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A nurse is assessing a client who has right-sided heart failure. Which of the following assessment findings should the nurse expect to find?

Nursing Test Bank

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A nurse is assessing a client who has right-sided heart failure.

Which of the following assessment findings should the nurse expect to find?