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 B

Explanation

A. Constipation can occur as a side effect of TPN due to decreased bowel motility, but it is not typically considered a serious complication.

B. Respiratory depression can occur as a complication of TPN, particularly if the solution contains high concentrations of dextrose or if the client has underlying respiratory issues.

C. Hypotension can occur as a complication of TPN if the solution is administered too rapidly, leading to fluid overload, but it is less common than respiratory depression.

D. Electrolyte imbalance, particularly hyperglycemia and hypertriglyceridemia, is a common complication of TPN, but it is less likely to cause immediate respiratory depression compared to other complications such as fluid overload.

A. Initiate an IV access for the client. B. Administer pain medication to the client. C. Send the client to radiology for a CT scan. D. Insert an NG tube for the client.

Correct Answer is A

Explanation

A. Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B. Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C. Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D. Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.

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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

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