A nurse is caring for a client in the outpatient cardiologist's office. The client is alert and oriented. Lung sounds with crackles are heard bilaterally. Dyspnea is observed on exertion, and heart sounds reveal an S3 gallop. Which of the following findings is the nurse most likely to expect?
Elevated blood pressure
Decreased respiratory rate
Pitting edema
Irregular pulse
The Correct Answer is C
Choice A rationale
Elevated blood pressure is a common finding in cardiovascular conditions but is not specifically indicated by the presence of crackles, dyspnea on exertion, or an S3 gallop.
Choice B rationale
A decreased respiratory rate is not typically associated with the presence of crackles and dyspnea; these symptoms are more indicative of increased work of breathing and potential fluid overload.
Choice C rationale
Pitting edema is a classic sign of fluid retention, which can be associated with heart failure. The presence of crackles, dyspnea on exertion, and an S3 gallop are clinical indicators that suggest heart failure, making pitting edema a likely finding.
Choice D rationale
An irregular pulse may be found in various cardiac conditions but is not directly suggested by the symptoms described. The presence of an S3 gallop is more indicative of heart failure, which is commonly associated with fluid overload signs such as pitting edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale
While infections can occur in IBD, the primary goal is not to combat infection but to manage the underlying inflammation¹.
Choice B rationale
Controlling inflammation is a key treatment goal in IBD to alleviate symptoms and induce and maintain remission².
Choice C rationale
Correcting and preventing malnutrition is essential in IBD management due to potential nutrient absorption issues¹.
Choice D rationale
Increasing stress is not a treatment goal for IBD. In fact, reducing stress can help manage IBD symptoms².
Choice E rationale
While IBD currently has no cure, the goals are to manage symptoms, induce remission, and improve quality of life².
Correct Answer is C
Explanation
Choice A rationale
Massaging the legs frequently is not recommended for peripheral venous disease as it can dislodge clots that may be present, leading to serious complications.
Choice B rationale
Keeping the legs in a dependent position can worsen the symptoms of peripheral venous disease by increasing venous pressure and swelling.
Choice C rationale
Inspecting the legs daily for changes is a key part of self-management for peripheral venous disease. It helps in early detection of potential complications.
Choice D rationale
Decreasing activity is not advised unless specified by a healthcare provider. Regular activity can actually help improve circulation and manage symptoms.
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