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

Answer and Explanation

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.

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Correct Answer is ["C","D","E","G"]

Explanation

The blood pressure is elevated. This may indicate a compensatory mechanism to try increases myocardial perfusion. However, this increases the oxygen demand worsening the condition.

Pain level of 7 indicates severe pain typical of acute coronary syndrome. The pain may worsen the extent of ischemia and hence morphine should be administered immediately

ECG findings are typical for myocardial infarction and intervention is key to prevent further myocardial damage.

Troponin levels are elevated due to damage of myocardium

Blood sugar level, bowel sounds and lung sounds are normal and therefore, requires no intervention.

A. "You will need to have the skin test annually." B. "You will need to follow up with your provider." C. "You will need to return in 48 hours for re-evaluation." D. "Your test will need to be repeated at this time."

Correct Answer is B

Explanation

B. The client's PPD skin test result of 12 mm induration is considered positive for individuals who are at increased risk of tuberculosis, such as those with recent exposure to tuberculosis or immunocompromised individuals. A positive PPD result typically requires follow-up with a healthcare provider for further evaluation, which may include chest X-rays, sputum cultures, and treatment for latent tuberculosis infection if indicated.
A. Annual PPD testing may be indicated for certain populations, such as healthcare workers or individuals at high risk of exposure to tuberculosis. However, the decision to repeat the PPD test annually should be based on individual risk factors and healthcare provider recommendations.
C. The PPD skin test is typically read 48-72 hours after administration to assess for induration.
D. A PPD skin test result of 12 mm induration is considered positive for individuals at increased risk of tuberculosis, but it does not necessarily indicate that the test needs to be repeated immediately.

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

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Correct Answer is ["C","D","E","G"]

Explanation

A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client?

Correct Answer is B

Explanation

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