A nurse is preparing to administer digoxin to a client who has left-sided heart failure.
Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).
Gastrointestinal bloating.
Jugular vein distention.
Tachycardia.
Orthopnea.
Dyspnea.
Correct Answer : C,D,E
Choice A rationale:
Gastrointestinal bloating is not a typical clinical manifestation of left-sided heart failure. Left-sided heart failure primarily affects the pulmonary circulation, leading to symptoms such as dyspnea and orthopnea, but not gastrointestinal symptoms.
Choice B rationale:
Jugular vein distention is more commonly associated with right-sided heart failure. In left-sided heart failure, the congestion typically occurs in the pulmonary circulation, leading to respiratory symptoms, whereas jugular vein distention is a sign of elevated central venous pressure often seen in right-sided heart failure.
Choice C rationale:
Tachycardia is a common clinical manifestation of left-sided heart failure. As the heart struggles to pump blood effectively, it compensates by increasing the heart rate to maintain cardiac output.
Choice D rationale:
Orthopnea is a classic symptom of left-sided heart failure. Clients with left-sided heart failure often experience difficulty breathing when lying flat and find relief when sitting upright. This is due to the redistribution of blood in the lungs when changing positions.
Choice E rationale:
Dyspnea is another hallmark symptom of left-sided heart failure. It is caused by the accumulation of fluid in the lungs (pulmonary edema) due to the impaired ability of the left ventricle to effectively pump blood, leading to congestion in the pulmonary circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.
Choice B rationale:
Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.
Choice C rationale:
Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.
Choice D rationale:
Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.
Correct Answer is C
Explanation
Choice A rationale:
"Pitting edema of the lower legs.”. Pitting edema is a common sign of congestive heart failure (CHF), and it often occurs bilaterally in the lower extremities. While this is a potential finding in left-sided heart failure, it is not specific to it.
Choice B rationale:
"Jugular venous distention.”. Jugular venous distention (JVD) is more indicative of right-sided heart failure or elevated central venous pressure. It is not a typical finding in left-sided heart failure.
Choice C rationale:
"Shortness of breath while lying down.”. This is a classic symptom of left-sided heart failure, known as orthopnea. When the patient lies flat, fluid that has accumulated in the lungs can lead to difficulty breathing. Patients with left-sided heart failure often find relief by sleeping with their upper body elevated.
Choice D rationale:
"Right upper quadrant pain.”. Right upper quadrant pain is not a typical finding in left-sided heart failure. It may be associated with issues related to the liver or gallbladder but is not directly related to heart failure.
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