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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Acupuncture is commonly used to treat a wide range of illnesses and ailments including pain management, control of nausea and vomiting, fatigue, hot flashes, xerostomia, neuropathy, anxiety, depression, and sleep disturbance in cancer patients.
However, I could not find any information that suggests mouth sores (B), headaches, or urticaria (D) are contraindications for acupuncture.
Lymphedema is a contraindication for acupuncture because it can increase the risk of infection in the affected area.
It is important for the nurse to identify this as a contraindication to receiving acupuncture therapy.
Correct Answer is C
Explanation
The nurse should place the client in a position with their feet elevated.
This position helps to increase blood flow to the vital organs and can help improve the client’s blood pressure.
Choice A is not the answer because the Reverse Trendelenburg position does not help improve blood flow to vital organs.
Choice B is not the answer because the side-lying position does not help improve blood flow to vital organs.
Choice D is not the answer because High-Fowler’s position does not help improve blood flow to vital organs.
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