A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
Pedal edema
Neck vein distention
Daytime oliguria
Enlarged liver
The Correct Answer is C
C. Oliguria can occur in severe cases of left-sided heart failure. When the heart's ability to pump blood forward is compromised, blood flow to the kidneys decreases, leading to decreased urine production.
A. Pedal edema is more commonly associated with right-sided heart failure.
B. Neck vein distention is typically associated with right-sided heart failure where increased pressure in the right side of the heart leads to jugular venous distention
D. Enlarged liver, or hepatomegaly, can occur in right-sided heart failure due to congestion and backup of blood in the hepatic circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Rationale
The frequency and amount of urination indicates that the body in able to utilize glucose reducing glucosuria and osmotic diuresis.
The ability to tolerate oral intake also indicates an improvement in the client’s general health
Improvement in perception of pedal pulses indicates an improvement in the hydration status of the client.
A normal pulse rate and blood pressure is an indicator of optimal hydration status- an improvement from the severely dehydrated state.
The blood glucose levels is dropping indicating an improvement in the glycemic control
Correct Answer is B
Explanation
B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.
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