A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Dizziness

Crackles in the lungs

Dry, hacking cough

Hepatomegaly

Answer and Explanation

The Correct Answer is D

A. Dizziness is not a primary finding of right ventricular failure but may be associated with other conditions.

B. Crackles in the lungs are more associated with left ventricular failure.

C. Dry, hacking cough is not a primary symptom of right ventricular failure but may be seen in left-sided heart failure.

D. Hepatomegaly is a common finding in right ventricular failure due to increased pressure in the venous system.

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Correct Answer is C

Explanation

A. Measuring the circumference of the thigh can help assess for swelling but is not specific for neurovascular assessment.
B. Palpating the femoral pulse is not as relevant for assessing neurovascular status at the site of a femur fracture; instead, the focus is on more distal pulses and sensations.
C. Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.
D. Monitoring the calf for edema is not the primary method for assessing neurovascular status at the site of a femur fracture; it’s more relevant for assessing for deep vein thrombosis.

A. Place the client in a supine position. B. Use log rolling to reposition the client. C. Place a warming blanket on the client. D. Instruct the client to cough and deep breathe.

Correct Answer is B

Explanation

A. Placing the client in a supine position can increase ICP. The head of the bed should be elevated 30-45 degrees to promote venous drainage from the head.
B. Using log rolling to reposition the client helps to maintain spinal alignment and prevent increases in ICP.
C. A warming blanket is not typically necessary unless the client is hypothermic; it does not directly affect ICP management.
D. Instructing the client to cough and deep breathe can increase ICP and should be avoided in clients with elevated ICP.

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A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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