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 ["A","B","D"]

Explanation

Decreased Lung Sounds: Could indicate complications such as pneumothorax.

Heart Rate 110/min: Tachycardia may suggest a reaction to recent procedures or other underlying issues.

Subcutaneous Emphysema: Indicates possible air leakage that needs to be addressed.

Does Not Require Immediate Follow-Up:

Oxygen Saturation of 95%: Indicates acceptable oxygenation status.

Trachea Midline: Shows that there is no mediastinal shift.

Puncture Site Dry: Indicates that there is no ongoing issue at the insertion site

A. Measure the circumference of the thigh. B. Palpate the femoral pulse. C. Instruct the client to wiggle his toes. D. Monitor the client's calf for edema.

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.

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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

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Correct Answer is C

Explanation

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