A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

Weight gain

Anorexia

Distended abdomen

Breathlessness

Answer and Explanation

The Correct Answer is D

Choice A: Weight gain is not a manifestation of left-sided heart failure. Weight gain is more likely to occur in right-sided heart failure, as the blood backs up in the systemic circulation and causes ﬂuid retention and edema in the body.

Choice B: Anorexia is not a manifestation of left-sided heart failure. Anorexia is a loss of appetite, which can have many causes, such as psychological disorders, infections, medications, or cancer. Left-sided heart failure does not directly affect appetite, but it can cause nausea, fatigue, and weakness.

Choice C: A distended abdomen is not a manifestation of left-sided heart failure. A distended abdomen is more likely to occur in right-sided heart failure, as the blood backs up in the portal vein and causes increased pressure in the liver and spleen. This can lead to hepatomegaly, splenomegaly, ascites, and varices.

Choice D: Breathlessness is a manifestation of left-sided heart failure. Breathlessness, or dyspnea, is a sensation of difficulty breathing or shortness of breath. Breathlessness occurs in left-sided heart failure, as the blood backs up in the lungs and causes pulmonary congestion and edema. This impairs gas exchange and reduces oxygen delivery to the tissues.

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Correct Answer is B

Explanation

The correct answer is: B. Initiate oxygen therapy.

Choice A reason:

Attaching the leads for a 12-lead ECG is crucial for diagnosing a myocardial infarction. However, it is not the first priority. Ensuring the patient receives adequate oxygen is more critical to prevent further myocardial damage. The ECG can be performed immediately after oxygen therapy is initiated to confirm the diagnosis and guide further treatment.

Choice B reason:

Initiating oxygen therapy is the first priority because it ensures that the heart muscle receives adequate oxygen, which is essential to prevent further damage during a myocardial infarction. Oxygen therapy helps to maintain tissue oxygenation and can reduce the extent of myocardial injury. This immediate intervention is vital to stabilize the patient and improve outcomes.

Choice C reason:

Inserting the IV catheter is important for administering medications and fluids. However, it is not the first step. Oxygen therapy takes precedence to ensure the heart and other vital organs receive sufficient oxygen. Once oxygen is administered, IV access can be established to facilitate further treatment.

Choice D reason:

Obtaining a blood sample is necessary for confirming the diagnosis and assessing cardiac markers. However, it is not the immediate priority. Ensuring the patient is oxygenated is more urgent to prevent further myocardial damage. Blood samples can be drawn after oxygen therapy is initiated.

A. Initiate droplet precautions. B. Administer an antitoxin. C. Initiate airborne precautions. D. Destroy the linens after use.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because droplet precautions are not sufficient to prevent the transmission of pneumonic plague. Droplet precautions are used to prevent the spread of infectious agents that are expelled through coughing, sneezing, or talking and travel only a short distance in the air. Droplet precautions include wearing a surgical mask, gown, and gloves, and placing the client in a private room or with a roommate who has the same infection.

Choice B Reason: This is incorrect because administering an antitoxin is not an intervention for pneumonic plague. An antitoxin is a substance that neutralizes the eﬀects of a toxin produced by a microorganism. Pneumonic plague is not caused by a toxin, but by a bacterial infection.

Choice C Reason: This is correct because initiating airborne precautions is an intervention for pneumonic plague. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Pneumonic plague is a severe and potentially fatal infection caused by the bacterium Yersinia pestis, which can be transmited through respiratory droplets or aerosols. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Airborne precautions include wearing a respirator or N95 mask, placing the client in a negative-pressure room with an air filtration system, and limiting visitors and staﬀ contact.

Choice D Reason: This is incorrect because destroying the linens after use is not an intervention for pneumonic plague. Linens that are contaminated with body ﬂuids or secretions should be handled with gloves and placed in leak-proof bags for laundering or disposal, but they do not need to be destroyed.

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A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

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Correct Answer is C

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