An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?
Fatigue.
Lower extremity edema.
Hepatomegaly.
Jugular vein distension.
The Correct Answer is A
Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the systemic circulation. This leads to fatigue and exertional dyspnea.
B. Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.
C. Hepatomegaly is a typical finding in right ventricular dysfunction
D. Jugular vein dysfunction is a typical finding in right ventricular dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Comparing the client's pain scale rating with the prescribed dosing ensures that the nurse selects the appropriate medication and dosage based on the severity of the client's pain. This action helps ensure safe and effective pain management by matching the intensity of the client's pain with the appropriate analgesic medication and dose.
A. Although this may be relevant in some situations, particularly if the client's pain requires rapid relief, the nurse should prioritize selecting the medication and dose based on the severity of the client's pain rather than solely on the onset of action.
C. The process does not address the immediate need to select the appropriate analgesic medication for the client's pain.
D. This may not be appropriate, especially if the client is in pain or unable to make an informed decision about which medication to choose.
Correct Answer is A
Explanation
A. Neutrophils are a type of white blood cell involved in the body's immune response, particularly in fighting bacterial infections. In the context of burns, especially full-thickness burns with purulent drainage, an elevated neutrophil count (neutrophilia) may indicate an ongoing infection. Burn wounds are susceptible to bacterial colonization and infection due to the loss of the skin's protective barrier.
B. Blood pH level refers to the acidity or alkalinity of the blood. While maintaining normal blood pH is crucial for overall health, changes in blood pH are not typically directly related to the presence of purulent drainage in burn wounds.
C. Serum albumin is a protein found in the blood that plays a role in maintaining osmotic pressure and transporting various substances, including drugs and hormones. Low serum albumin levels (hypoalbuminemia) can occur in individuals with severe burns due to increased protein loss through damaged skin and decreased protein synthesis. However, it is not directly related to evaluating purulent drainage from burn wounds.
D. Platelet count: Platelets are blood cells involved in clotting, which is essential for wound healing. While thrombocytopenia (low platelet count) can occur in individuals with severe burns,it is not directly related to assessing infection in burn wounds.
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