A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Tachycardia

Weight gain

Decreased thirst

Thready pulse

Answer and Explanation

The Correct Answer is B

A.   While tachycardia can occur in some cases of heart failure as a compensatory mechanism, it's not a universal manifestation.
B.   In heart failure, weight gain is a common manifestation due to fluid retention caused by the heart's inability to pump blood effectively. This fluid buildup can lead to an increase in body weight, often evidenced by swelling in the legs, ankles, or abdomen.
C.   Heart failure often leads to increased thirst due to fluid overload and decreased cardiac output, resulting in poor tissue perfusion.
D.   A thready pulse may be present in heart failure due to decreased stroke volume, but it's not a primary manifestation typically associated with the condition.

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Correct Answer is A

Explanation

A. Flushing the NG tube with 0.9% sodium chloride helps maintain patency and prevents obstruction. It is a standard practice to flush NG tubes before and after administering medications or feedings.
B. NG tubes are not routinely replaced every 24 hours unless there is a specific clinical indication to do so.
C. The position of the client depends on the clinical situation, but supine position alone does not address NG tube care.
D. Suction pressure should be set according to the physician's orders and the patient's tolerance, but it should not be increased arbitrarily without clinical indication.

A. Flattening of the artificial airway cuff B. Decreased peak inspiratory pressure C. Thinning of mucous secretions D. Presence of a productive cough

Correct Answer is B

Explanation

A. Flattening of the artificial airway cuff. This would indicate a problem, such as a leak, not a successful outcome of suctioning.
B. This indicates that the airway resistance has been reduced following suctioning, which suggests that the suctioning was effective in clearing the airway obstruction caused by secretions.
C. Thinning of mucous secretions is not a direct indication of effective suctioning; while thinner secretions may be easier to remove, the goal of suctioning is to clear the airways rather than alter the consistency of the secretions.
D. The presence of a productive cough is not relevant in the context of a patient who is intubated and mechanically ventilated, as they would be unable to cough effectively due to the endotracheal tube.

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A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

Correct Answer is B

Explanation

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