A nurse is caring for an older adult patient with left-sided heart failure. What assessment findings should the nurse expect?
Frothy sputum.
Dependent edema.
Nocturnal polyuria.
Jugular distention.
The Correct Answer is A
Choice A rationale
Frothy sputum is a common finding in patients with left-sided heart failure. This is due to fluid accumulation in the lungs (pulmonary edema), which can cause the sputum to become frothy.
Choice B rationale
Dependent edema is more commonly associated with right-sided heart failure. It occurs due to fluid accumulation in the systemic circulation, leading to swelling in the lower extremities.
Choice C rationale
Nocturnal polyuria can occur in heart failure, but it is not a specific sign of left-sided heart failure.
Choice D rationale
Jugular venous distention is a sign of right-sided heart failure, not left-sided heart failure. It occurs due to increased pressure in the right atrium, leading to visible distention of the jugular veins.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Phosphate levels are not directly affected by spironolactone. Spironolactone is a potassium- sparing diuretic and does not typically affect phosphate levels.
Choice B rationale
Decreased potassium level is not typically expected in a patient taking spironolactone. Spironolactone is a potassium-sparing diuretic, meaning it can actually lead to increased potassium levels. However, in the context of liver failure and ascites, other factors may influence potassium levels.
Choice C rationale
Chloride levels are not directly affected by spironolactone. Spironolactone primarily affects the balance of potassium and sodium in the body.
Choice D rationale
Sodium levels could potentially be decreased in a patient taking spironolactone, as it can cause the body to lose sodium. However, in the context of liver failure and ascites, sodium levels are often carefully managed.
Correct Answer is B
Explanation
Choice A rationale
Lower quadrant pain is a common symptom of many conditions, including ectopic pregnancy. However, it does not specifically indicate the presence of blood in the peritoneum.
Choice B rationale
Cullen’s sign, which is the appearance of bruising in the skin around the umbilicus, is a sign of blood in the peritoneum. It can occur in conditions such as a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a softening of the cervix that typically occurs early in pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia that occurs in early pregnancy. It does not indicate the presence of blood in the peritoneum.
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