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

Crackles

Productive cough

Hepatomegaly

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.

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Correct Answer is B

Explanation

A. Serum potassium 4.8 mEq/L: A potassium level of 4.8 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this is not a reason to withhold digoxin.

B. Report of blurred vision: Blurred vision can be a sign of digoxin toxicity, especially if the client sees yellow or green halos. This is an indication to withhold the medication and notify the provider.

C. Urine output 35 mL/hr: A urine output of 35 mL/hr is slightly below the average but not critical enough to withhold digoxin. Digoxin is not directly related to urine output.

D. Heart rate 66/min: A heart rate of 66/min is within the normal range. However, digoxin should be withheld if the heart rate is below 60 bpm, but in this case, the heart rate is adequate.

A. "Be sure to wear this equipment for the next 24 hours. B. You might feel some slight tingling during the procedure." C. Try to remain still once I have attached the gel pads. D. "I will be placing some electrodes on your scalp."

Correct Answer is C

Explanation

A. "Be sure to wear this equipment for the next 24 hours." This statement applies to a Holter monitor, not a 12-lead ECG. A 12-lead ECG is a brief, one-time test.

B. "You might feel some slight tingling during the procedure." A 12-lead ECG does not involve any sensation like tingling. It simply records the heart’s electrical activity without causing any discomfort.

C. "Try to remain still once I have attached the gel pads." Movement during an ECG can interfere with the results by causing artifact, so it's important for the client to remain still while the test is being performed.

D. "I will be placing some electrodes on your scalp."Electrodes for a 12-lead ECG are placed on the chest and limbs, not on the scalp.

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

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a client who has heart failure. For which of the following findings should the nurse withhold the medication and report to the provider?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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