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 D
Explanation
D. Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
A. Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention
Correct Answer is C
Explanation
Request an interpreter during the initial assessment involves requesting the assistance of a qualified sign language interpreter to facilitate communication between the nurse and the client who is deaf. This is generally considered the most appropriate and effective option for ensuring accurate and clear communication during the admission process.
A. It may not be feasible for the nurse to become fluent in sign language immediately, learning commonly used signs can help establish basic communication and demonstrate respect for the client's communication needs. However, relying solely on this option may not be sufficient for complex communication needs or during emergencies.
B. Obtaining a board that uses colored pictures as communication may not fully address the client's needs, especially if they primarily use sign language. This option might be useful as a supplementary aid but may not be the most effective method for initial communication.
D. While having a family member present can be helpful, especially if they are proficient in sign language, it may not always be feasible or reliable. Additionally, relying on family members for interpretation can compromise the client's privacy and confidentiality, as well as potentially introduce biases or misunderstandings in communication.
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