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 D

Explanation

D. Hanging a monthly calendar in the client's bedroom provides a visual aid for tracking important dates and events, which can help maintain their sense of routine and structure.
A. Keeping the client's bedroom dark at night may increase confusion and disorientation, especially if the client wakes up during the night.
B. Placing a large-face clock in the client's bedroom allows them to easily see and understand the time, which can help orient them to the day and reduce confusion. However, it may become monotonous for the client.
C. While it's essential to childproof the home to prevent accidents, covering electrical outlets with tape may not effectively prevent access to them and can pose a fire hazard.

A. Initiate IV fluid replacement. B. Measure the client's urinary output. C. Administer insulin. D. Teach the client about manifestations of HHS

Correct Answer is A

Explanation

A. Initiate IV fluid replacement is the highest priority intervention. HHS is characterized by severe dehydration due to osmotic diuresis resulting from hyperglycemia. IV fluid replacement is essential to correct dehydration and restore intravascular volume, which can help improve tissue perfusion and prevent further complications.
B. Monitoring urinary output is important in assessing renal function and response to fluid replacement therapy. However, it is not the highest priority intervention.
C. While insulin therapy is an essential part of managing hyperglycemia in HHS, it is not the highest priority intervention at the immediate onset of HHS.

D. Patient education about the manifestations and management of HHS is important for long-term management and prevention of recurrence. However, it is not the highest priority when the client is experiencing an acute episode of HHS.

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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

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Correct Answer is A

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