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 D
Explanation
Choice A rationale
Percussion between the iliac crest and ribs at the midaxillary line is not the standard method for assessing flank tenderness associated with pyelonephritis. This technique may not elicit the characteristic pain of kidney inflammation.
Choice B rationale
Pushing fingers upward into the two lowest intercostal spaces is not a specific test for flank tenderness and may not accurately assess for pyelonephritis. This action is more related to assessing the integrity of the rib cage and intercostal muscles.
Choice C rationale
Palpating along both sides of the lumbar vertebral column is not the correct method for assessing flank tenderness due to pyelonephritis. This approach is more suited for assessing the musculoskeletal structure rather than the kidneys.
Choice D rationale
Striking a flat hand over the costovertebral angle is the correct method for assessing flank tenderness in cases of suspected pyelonephritis. This technique, known as costovertebral angle tenderness, elicits pain when the kidneys are inflamed, which is a common sign of pyelonephritis.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Anxiety, while a valid concern, is not directly a risk associated with the physical complications of an ileal conduit. However, it can be an emotional response to the surgery and the changes it brings.
Choice B rationale
Impaired skin integrity is a significant risk for clients with an ileal conduit due to the potential for irritation from the stoma appliance and the risk of skin breakdown around the stoma site.
Choice C rationale
Infection is a risk due to the potential for bacteria to enter through the stoma or for urinary tract infections to develop, given the changes in the urinary system's structure and function.
Choice D rationale
Fluid volume deficit is a risk for clients with an ileal conduit because of the potential for increased fluid loss through the stoma, necessitating careful monitoring and management of fluid intake and output.
Choice E rationale
Disturbed body image is a risk due to the physical changes and the presence of a stoma, which can affect the client's perception of their body and self-image.
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