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

Crackles in lungs.

Decreased thirst.

Poor skin turgor.

Tachycardia.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Crackles in the lungs are a common manifestation of heart failure. Heart failure can cause fluid accumulation in the lungs, leading to crackles upon auscultation. This finding is due to pulmonary congestion and is indicative of heart failure exacerbation.

Choice B rationale:

Decreased thirst is not a typical manifestation of heart failure. In fact, patients with heart failure often experience increased thirst due to fluid shifts and increased blood volume, leading to increased urine output and dehydration.

Choice C rationale:

Poor skin turgor is not a specific manifestation of heart failure. Skin turgor is commonly assessed to determine hydration status, but it is not directly related to heart failure.

Choice D rationale:

Tachycardia (rapid heart rate) is a common manifestation of heart failure. The heart beats faster to compensate for its decreased pumping efficiency. Tachycardia helps maintain cardiac output, but it is not a primary cause of heart failure; instead, it is a physiological response to the condition.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Explanation: Evisceration is a surgical emergency that occurs when the abdominal contents protrude through the incision site. The nurse should instruct the client to lie supine with his knees flexed to reduce tension on the wound and prevent further damage.

The nurse should also cover the wound with a moist sterile dressing and notify the surgeon immediately. Positioning the client in semi-Fowler's position, covering the wound with a dry sterile dressing, or covering the wound with a transparent dressing are not appropriate actions for evisceration.

A. "What has helped you through difficult times in the past?" B. "Is there anyone you would like involved in your care?" C. "Has anyone in your family committed suicide?" D. "Are you thinking about ending your life?" .

Correct Answer is D

Explanation

Choice A rationale:

Asking about past coping mechanisms can provide valuable information, but in this situation, where the client is expressing thoughts of hopelessness, it's crucial to assess the immediate risk of suicide. Therefore, this choice is not the best option in this context.

Choice B rationale:

Involving significant others in the client's care is important, but it doesn't address the client's current emotional state and suicidal ideation. This choice does not take priority in this scenario.

Choice C rationale:

While exploring family history, including suicide, is relevant, it's not the first question to ask. Assessing the client's current thoughts and feelings should be the priority before delving into family history. Therefore, this choice is not the best option at this moment.

Choice D rationale:

(Correct Choice) This is the most appropriate question to ask first. Assessing the client's suicidal ideation is crucial for ensuring their safety. If the client expresses suicidal thoughts, the nurse can take immediate steps to keep the client safe, such as involving a mental health professional or initiating a suicide risk assessment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

Correct Answer is D

Explanation

A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (Select all that apply.)

A nurse is reviewing the medication administration record of a client.Which of the following prescriptions should the nurse clarify?

A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client. Which of the following actions should the nurse take first?

A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh.Which of the following actions should the nurse take?

A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu.The nurse should recognize which of the following findings as a potential contraindication for using lavender?

A nurse is caring for a client who has diabetes mellitus and is receiving long-acting daily insulin for blood glucose management.The nurse should anticipate administering which of the following types of insulin?

A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk.After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test?

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