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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The nurse should first administer the client's cefazolinto the client's IV access
Rationale:
Cefazolin is an antibiotic prescribed to treat the client's suspected infection indicated by the fever and hip surgical wound inflammation. Administering the antibiotic promptly is essential to initiate treatment and address the underlying cause of the fever. The prescription specifies administering cefazolin intravenously, so the nurse should prioritize administering it through the client's IV access. Administering acetaminophen or alprazolam may be appropriate based on the client's symptoms and vital signs, but addressing the infection with antibiotics takes precedence.
Correct Answer is B
Explanation
A. The wall suction setting does not directly indicate the functioning of the NG tube.
B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting
that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.
C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.
D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.
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