A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

Crepitus

Elevated pulmonary artery pressure

Hepatosplenomegaly

Confusion

Answer and Explanation

The Correct Answer is B

A. Crepitus is a finding associated with subcutaneous emphysema or gas accumulation under the skin, typically not directly related to right ventricular heart failure.

B. Right ventricular heart failure can lead to increased pressure in the pulmonary artery, resulting in symptoms such as dyspnea, fatigue, and possibly right-sided heart murmurs.

C. Hepatosplenomegaly (enlargement of the liver and spleen) is more commonly associated with conditions such as liver cirrhosis, not specifically right ventricular heart failure.

D. Confusion is not typically associated with right ventricular heart failure unless there are complications such as hypoxemia or impaired cerebral perfusion.

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Correct Answer is D

Explanation

A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.

B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.

C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.

D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.

A. Holding the newborn in an en face position B. Asking the father to change the newborn's diaper C. Viewing the newborn's actions to be uncooperative D. Requesting the nurse take the newborn to the nursery so she can rest

Correct Answer is C

Explanation

A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.

B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.

C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding

infant cues, requiring the nurse's intervention.

D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.

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A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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