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 B
Explanation
The correct answer is B.
Choice A reason: Avoid preparing medications for more than two clients at one time is a guideline aimed at reducing the risk of medication errors. However, it is not an absolute rule and may vary depending on the setting and resources available.
Choice B reason: Inform clients about the action of each medication prior to administration. This practice is essential for patient education, ensuring that patients are informed about what medications they are taking and why, which can improve adherence and outcomes.
Choice C reason: Reading medication labels at least two times prior to administration is a good practice to avoid errors, but it is not always specified as a standard requirement in medication administration guidelines.
Choice D reason: Completing an incident report if a client vomits after taking a medication is necessary only if the vomiting is related to an adverse drug reaction or a medication error, not for routine vomiting.
Correct Answer is B
Explanation
Choice A rationale:
Acetone breath is a symptom of diabetic ketoacidosis (DKA), a complication of diabetes mellitus. It occurs due to the presence of ketones in the breath and is not specific to hypoglycemia. Hypoglycemia is characterized by low blood sugar levels, not elevated ketone levels.
Choice B rationale:
Confusion is a common symptom of hypoglycemia. When blood sugar levels drop significantly, the brain may not receive enough glucose to function properly, leading to confusion, dizziness, and other neurological symptoms.
Choice C rationale:
Polydipsia refers to excessive thirst and is a symptom of hyperglycemia (high blood sugar levels), not hypoglycemia. In hyperglycemic states, the body tries to eliminate excess glucose through urine, leading to increased thirst.
Choice D rationale:
Hot, dry skin is not a typical symptom of hypoglycemia. Hypoglycemia can cause diaphoresis (excessive sweating) and cool, clammy skin due to the body's stress response.
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