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

Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.

A. 2.5 mL. B. 25 mL. C. 2.05 mL. D. 2.25 mL.

Correct Answer is A

Explanation

Let’s break down the problem step by step:

Step 1: Convert the client’s weight from pounds (lb) to kilograms (kg). We know that 1 kg = 2.2 lbs. So, we have: 220 lb ÷ 2.2 = 100 kg

Step 2: Calculate the total amount of naloxone needed. The doctor ordered 10 mcg/kg, and the client weighs 100 kg. So, we have: 10 mcg/kg × 100 kg = 1000 mcg

Step 3: Convert micrograms (mcg) to milligrams (mg). We know that 1 mg = 1000 mcg. So, we have: 1000 mcg ÷ 1000 = 1 mg

Step 4: Calculate the volume of naloxone solution needed. The available naloxone solution is 0.4 mg/mL. So, we have: 1 mg ÷ 0.4 = 2.5 mL

So, the nurse should administer 2.5 mL of naloxone. Since we are asked to round off to the nearest tenth, the final answer remains 2.5 mL.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report?

Correct Answer is C

Explanation

A nurse is preparing to administer naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lb. The amount available is 0.4 mg/mL. How many mL should the nurse administer? (round off to the nearest tenth)

Correct Answer is A

Explanation

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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?