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

Answer and Explanation

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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Correct Answer is A

Explanation

a. A client taking furosemide for chronic hypertension: Furosemide is a loop diuretic that can

lead to hypokalemia, which increases the risk of digoxin toxicity, as hypokalemia potentiates the effects of digoxin on the heart.

b. A client taking a potassium supplement twice a day: Potassium supplementation reduces the risk of digoxin toxicity, as hypokalemia is a risk factor for toxicity.

c. A client taking aluminum hydroxide for gastric upset: Aluminum hydroxide is an antacid and does not significantly affect digoxin levels.

d. A client taking chlorpropamide for type 2 diabetes mellitus: Chlorpropamide is an oral hypoglycemic agent and does not significantly affect digoxin levels.

A. Incisional infection B. Paralytic ileus C. Health care-associated Clostridium difficile D. Fecal impaction

Correct Answer is B

Explanation

b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.

c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.

d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the

rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.

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A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

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