A nurse working in the cardiac icu is caring for client with suspected left sided heart failure. For which clinical manifestation should the nurse assess for?

Crackles upon auscultation

Palpable liver during assessment

Pitting Edema

Distended jugular veins

Answer and Explanation

The Correct Answer is A

A) Crackles upon auscultation:
Left-sided heart failure occurs when the left ventricle is unable to effectively pump blood to the body, causing blood to back up into the lungs. This results in pulmonary congestion, which often manifests as crackles (also called rales) upon auscultation, particularly in the lower lobes of the lungs. The crackles are caused by the fluid accumulation in the alveoli, a hallmark sign of left-sided heart failure.

B) Palpable liver during assessment:
A palpable liver is more commonly associated with right-sided heart failure. In right-sided heart failure, the blood backs up into the venous system, causing congestion in organs such as the liver and spleen. This leads to hepatomegaly (enlargement of the liver), which can be palpated during physical examination. Therefore, a palpable liver is not typically a manifestation of left-sided heart failure.

C) Pitting Edema:
Pitting edema is more characteristic of right-sided heart failure. When the right ventricle is unable to pump blood effectively, blood backs up in the systemic circulation, leading to fluid retention and edema in the lower extremities, abdomen (ascites), or other dependent areas. While pitting edema can occur in left-sided heart failure, it is more commonly a finding in right-sided heart failure or congestive heart failure.

D) Distended jugular veins:
Distended jugular veins (JVD) are also a sign of right-sided heart failure, not left-sided heart failure. When the right side of the heart fails, blood backs up in the venous system, leading to increased venous pressure, which can be observed as jugular venous distension. This is a key finding in right-sided heart failure.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A) Stop taking ordered corticosteroid once symptoms resolve:
Corticosteroids, such as prednisone, are commonly prescribed to reduce inflammation in Bell’s Palsy, especially during the acute phase. However, it is important to complete the full course of corticosteroids as prescribed, even if symptoms improve. Abruptly stopping corticosteroids can lead to rebound inflammation and potentially worsen the condition.

B) Apply warm compresses to the affected area several times a day:
Warm compresses can help to reduce pain and inflammation in the affected side of the face. Applying them several times a day can also help improve circulation and ease the discomfort associated with Bell's Palsy. This is a recommended self-care strategy that can help provide relief and improve overall comfort for the client during recovery.

C) Cover the affected eye with an eye protective shield or patch at night:
Bell's Palsy can lead to paralysis of the facial muscles, which may make it difficult for the client to fully close the eyelid on the affected side, leaving the eye vulnerable to dryness and injury. Covering the eye with a protective shield or patch at night helps prevent corneal damage and protects the eye from exposure during sleep. This is an essential part of eye care for a client with Bell’s Palsy to prevent complications.

D) Chew food only on the affected side:
There is no medical recommendation to limit chewing to the unaffected side. In fact, clients should be encouraged to use both sides of their mouth for chewing to prevent muscle atrophy and maintain function. There is no evidence to support that chewing food only on the affected side provides any benefit.

E) Place artificial tears or lubricant to help decrease dryness in the eyes:
Since Bell's Palsy can impair the ability to close the eyelid fully, this can lead to dryness and potential corneal damage on the affected side. Artificial tears or lubricating eye drops should be used regularly to moisturize the eye and prevent complications such as corneal ulcers or abrasions.

A. The UAP stands by the patient's bed for 60 minutes talking with the patient. B. The UAP gives the patient a saline mouthwash to use for oral care. C. The UAP places the patient's bedding in the laundry container inside the clients room. D. The UAP flushes the toilet twice after emptying the patient's bedpan.

Correct Answer is A

Explanation

A) The UAP stands by the patient's bed for 60 minutes talking with the patient:
This action requires immediate intervention because of the potential radiation exposure to the UAP. A temporary radioactive cervical implant involves placing a radioactive source in or near the patient's cervix. This implant emits radiation, and safety precautions are essential to limit exposure to others, including healthcare workers. Prolonged close contact, such as standing by the patient's bed for 60 minutes, increases the risk of radiation exposure to the UAP.

B) The UAP gives the patient a saline mouthwash to use for oral care:
There are no specific contraindications to using a saline mouthwash for oral care in patients with a radioactive implant. Saline mouthwash is commonly recommended for patients undergoing radiation therapy to soothe the mouth and prevent dryness or irritation. As long as the UAP is following standard infection control and safety precautions.

C) The UAP places the patient's bedding in the laundry container inside the client's room:
Bedding and linens from a patient with a radioactive implant can usually be handled and disposed of according to hospital guidelines for radioactive waste. Often, these linens are not considered to pose a significant radiation hazard after removal from the patient’s immediate area, especially if the patient is not emitting radiation outside the prescribed safety guidelines.

D) The UAP flushes the toilet twice after emptying the patient's bedpan:
After the patient has a radioactive implant, any bodily waste (urine, stool) can potentially contain small amounts of radiation. Flushing the toilet twice helps to ensure that any radioactive materials are effectively cleared. However, the UAP should be instructed to wear gloves and take other precautions to prevent contamination while handling the bedpan and ensuring proper disposal of waste.

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A nurse working in the cardiac icu is caring for client with suspected left sided heart failure. For which clinical manifestation should the nurse assess for?

Nursing Test Bank

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is A

Explanation

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