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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Diazepam (Valium) is not the correct choice in this situation. Diazepam is a sedative and muscle relaxant but would not address the respiratory depression caused by hydromorphone. The client's respiratory rate of 10/min indicates a potential opioid overdose, and the appropriate intervention is to administer naloxone to reverse the opioid effects.
Choice B rationale:
Acetaminophen (Tylenol) is not the correct choice in this scenario. Acetaminophen is a pain reliever and fever reducer but would not address the respiratory depression caused by hydromorphone. The priority is to address the respiratory depression promptly with naloxone.
Choice C rationale:
Ibuprofen (Advil) is not the correct choice in this situation. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation but is not appropriate for reversing opioid-induced respiratory depression. Naloxone is the drug of choice to reverse opioid overdose in this case.
Choice D rationale:
Naloxone (Narcan) is the correct choice. Naloxone is an opioid receptor antagonist used to reverse the effects of opioid overdose, including respiratory depression. Given the client's low respiratory rate, naloxone should be administered promptly to counteract the effects of hydromorphone. This is the most appropriate and potentially life-saving intervention for this client.
Correct Answer is B
Explanation
In the context of an emergency response plan following an external disaster and the need to create bed space for potential admissions, the nurse should consider early discharge for clients who are stable and whose discharge will not compromise their safety or health. Based on the given options, the most appropriate candidate for early discharge would be:
B) A client who is 1 day postoperative following a vertebroplasty.
Clients who are one day postoperative after a vertebroplasty are typically recovering from a relatively minor procedure and may be stable for discharge if their condition remains uncomplicated.
The other options:
A) A client receiving heparin for deep-vein thrombosis may require ongoing monitoring and treatment, and early discharge might not be appropriate.
C) A client with cancer and a sealed implant for radiation therapy likely has specific treatment needs and should not be discharged early.
D) A client with COPD and a respiratory rate of 44/min likely has respiratory distress and should not be discharged early. Their condition requires close monitoring and intervention.
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