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.

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Correct Answer is D

Explanation

A. Review the need for the UAP to wear a face mask while in close contact with the client. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Assign the UAP to provide care for another client and assume full care of the client. D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

The client has influenza, which is a respiratory illness that can be transmitted through droplets when the infected person coughs, sneezes, or talks. The UAP is in close contact with the client while assisting them to sit up in bed to eat lunch. Therefore, it is necessary for the UAP to wear a face mask in addition to a gown and gloves to prevent the spread of the virus.This is in line with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that healthcare personnel wear a face mask when they are in the same room as a patient with suspected or confirmed influenza.

Choice B rationale:

A fitted respirator mask is not necessary in this situation.According to the Occupational Safety and Health Administration (OSHA), respirators are required for airborne diseases such as tuberculosis, but not for influenza, which is a droplet-transmitted disease. Therefore, reminding the UAP to apply a fitted respirator mask before entering the client’s room is not the most appropriate action.

Choice C rationale:

Assigning the UAP to provide care for another client and assuming full care of the client is not the most appropriate action in this situation. The UAP is already wearing a gown and gloves, which are part of the standard precautions for any patient care.The UAP just needs to add a face mask to their personal protective equipment (PPE) to safely assist the client.

Choice D rationale:

Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is always a good practice. However, it does not address the immediate need for the UAP to wear a face mask while in close contact with the client. Therefore, it is not the most appropriate action in this situation.

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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

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