Try Naxlex NCLEX-RN (Free-Trial)

A nurse us collecting data from a client who has right sided heart faiulure. Which of the following should the nurse expect?

A.

Crackles

B.

Productive cough

C.

Hepatomegaly

D.

Dizziness

Answer and Explanation

The Correct Answer is C

A. Crackles: Crackles in the lungs are a sign of left-sided heart failure, as fluid backs up into the pulmonary system.

B. Productive cough: A productive cough is also more commonly associated with left-sided heart failure, as it can result from fluid accumulation in the lungs.

C. Hepatomegaly:  Hepatomegaly is a sign of right-sided heart failure, as blood backs up into the systemic circulation, leading to congestion in the liver.

D. Dizziness: Dizziness may occur in left-sided heart failure due to decreased cardiac output, but it is not a typical finding in right-sided heart failure.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is B

Explanation

A. Attach the leads for a 12-lead ECG. While a 12-lead ECG is important in diagnosing chest pain, the client’s oxygenation is a priority and should be addressed before further diagnostics.

B. Initiate oxygen therapy. The priority in this scenario is to address the client's cyanosis and shortness of breath. Oxygen therapy improves oxygen delivery to tissues and should be the first intervention.

C. Obtain a blood sample. Obtaining cardiac enzyme levels is necessary for diagnosing myocardial infarction, but oxygen therapy should be initiated first to address immediate respiratory distress.

D. Insert the IV catheter. Inserting an IV catheter is important for administering fluids and medications, but it is not the most urgent action in the presence of hypoxia.

Correct Answer is B

Explanation

A. "I’ll be sure to eat foods with lots of vitamin K." This statement shows misunderstanding, as vitamin K counteracts the effects of warfarin. The client should maintain a consistent intake of vitamin K, not increase it.

B. "I’ll use my electric razor for shaving." Using an electric razor reduces the risk of cuts, which could lead to bleeding, a common concern for clients on warfarin.

C. "It's okay to have a few glasses of wine every day." Alcohol can interfere with the metabolism of warfarin and increase the risk of bleeding. This is not a safe practice.

D. "I'll take aspirin for my headaches." Aspirin is an anticoagulant and can increase the risk of bleeding when taken with warfarin, so this statement indicates a lack of understanding.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register