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. “You may feel some cramping during the procedure.” - This response provides an honest and accurate expectation of potential discomfort during the colonoscopy.

B. “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” - Sedation may help with recall, but it doesn't eliminate the possibility of feeling discomfort.

C. “Most clients report more discomfort from the preparation than from the procedure itself.” - While this statement is generally true, it doesn't directly address the client's concern about pain during the colonoscopy.

D. “You shouldn’t feel any pain since the local area is anesthetized.” - Colonoscopy is typically done with conscious sedation rather than local anesthesia, and some discomfort may still be felt.

A. Maintain the client on bed rest. B. Strain the client's urine through a mesh filter. C. Encourage fluid intake of 1500 mL/day. D. Clamp the urinary catheter every 2 hr.

Correct Answer is B

Explanation

a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.

b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.

c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.

d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard

intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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