A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Orthopnea
Peripheral edema
Frothy sputum
Dyspnea
The Correct Answer is B
a. Orthopnea: Orthopnea is more commonly associated with left-sided heart failure, where fluid backs up into the lungs, making it difficult to breathe when lying down.
b. Peripheral edema: Right-sided heart failure can lead to systemic venous congestion, resulting in peripheral edema, often evident in the lower extremities.
c. Frothy sputum: Frothy sputum is more indicative of pulmonary edema, which is associated with left-sided heart failure.
d. Dyspnea: While dyspnea can occur with right-sided heart failure, it is more characteristic of left-sided heart failure.
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Related Questions
Correct Answer is D
Explanation
a. Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.
b. Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.
c. Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.
d. Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.
Correct Answer is A
Explanation
a. Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.
b. Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.
c. Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.
d. Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.
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