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. Wearing an underwire bra between feedings can compress the breasts and potentially lead to mastitis. Nursing bras without underwire are recommended.

B. Covering the breasts immediately after feedings can trap moisture and promote bacterial growth, increasing the risk of mastitis.

C. Cold compresses can help relieve discomfort from engorgement, but applying them before feedings may hinder milk flow and emptying of the breasts, which could increase the risk of mastitis.

D. Ensuring the baby fully empties the breasts with each feeding helps prevent engorgement and decreases the risk of mastitis by promoting effective milk removal.

A. "Do you understand HIPAA regulations?" B. "This discussion is only appropriate in a private area." C. "Please stop this discussion." D. "Did you know you can be liable if you breach confidentiality?"

Correct Answer is C

Explanation

A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.

B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.

C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.

D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.

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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?

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