A nurse is providing teaching to a client who has left-sided heart failure. Which of the following manifestations should the nurse include in the teaching?

Neck-vein distention

Ankle edema

Anorexia

Hacking cough

Answer and Explanation

The Correct Answer is D

A hacking cough, especially at night or when lying down, is a common manifestation of left-sided heart failure, as fluid accumulates in the lungs and causes pulmonary congestion and dyspnea. Neck-vein distention and ankle edema are more indicative of right-sided heart failure, as fluid backs up into the systemic circulation and causes peripheral edema and jugular venous pressure elevation. Anorexia may occur in either type of heart failure, but it is not specific to left-sided heart failure.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

A. Use a 10-mL syringe to flush the line. B. Do not elevate the arm above the level of the heart. C. Change the catheter dressing daily. D. Clean the insertion site using 20 mL of hydrogen peroxide.

Correct Answer is A

Explanation

The nurse should instruct the client to use a 10-mL syringe or larger to flush the PICC line with normal saline or heparin solution, as prescribed, to prevent occlusion and thrombosis. The other options are incorrect because they may cause complications such as infection, phlebitis, or bleeding.

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A nurse is providing teaching to a client who has left-sided heart failure. Which of the following manifestations should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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