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 not typically associated with right ventricular heart failure; it may indicate subcutaneous emphysema or air leakage into the tissues.
B. Right ventricular heart failure often leads to elevated pulmonary artery pressure due to increased pressure in the pulmonary circulation.
C. Hepatosplenomegaly may occur in congestive heart failure but is not specific to right ventricular heart failure.
D. Confusion may occur in severe cases of heart failure due to decreased cerebral perfusion, but it is not specific to right ventricular heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While creating a flexible daily schedule may be helpful, it does not directly address the core symptoms of OCD.
B. Gradually decreasing the time allowed for ritualistic behavior is a common technique used in exposure and response prevention therapy, which is an evidence-based treatment for OCD.
C. Offering solutions for problem-solving may be helpful in general, but it may not directly address the specific symptoms of OCD.
D. While meditation can be beneficial for managing stress and anxiety, it may not specifically address the compulsive thoughts and behaviors characteristic of OCD.
Correct Answer is D
Explanation
A. Inserting an indwelling catheter involves an invasive procedure and assessment of urinary output and client status, which falls within the RN’s scope of practice in a high-risk client such as one with acute liver failure.
B. Obtaining abdominal girth requires assessment skills and interpretation for changes in ascites, which is more appropriate for the RN to ensure accurate monitoring.
C. Assessing and documenting level of consciousness is a critical assessment, especially in liver failure where hepatic encephalopathy is a risk. This is within the RN’s responsibility because changes can be subtle and require immediate intervention.
D. Measuring the amount of gastric drainage every 2 hours is a stable, routine task that follows established parameters and does not require advanced assessment skills. It is within the LPN’s scope and can be safely delegated, with the RN overseeing interpretation of any abnormal findings.
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