The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

Jugular vein distention.

Bilateral basilar crackles.

3+ pitting enema in the ankles.

Hepatomegaly with right upper quadrant (RUQ) tenderness.

Answer and Explanation

The Correct Answer is B

Choice A reason: Jugular vein distention is more commonly associated with right ventricular heart failure, as it indicates increased central venous pressure.

Choice B reason: Bilateral basilar crackles are a hallmark sign of left ventricular heart failure. They occur due to pulmonary congestion and enema, resulting from the left ventricle's inability to effectively pump blood out to the body, causing fluid to back up into the lungs.

Choice C reason: 3+ pitting enema in the ankles is more characteristic of right ventricular heart failure, where fluid accumulates in the peripheral tissues.

Choice D reason: Hepatomegaly with right upper quadrant (RUQ) tenderness is also more indicative of right ventricular heart failure, as it reflects congestion in the liver due to increased venous pressure.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Placing the client in a darkened room may help alleviate symptoms if the headache is related to migraine or sensitivity to light, but it does not address the potential underlying cause of the severe headache and blurred vision in a client with a history of diabetes and hypertension.

Choice B reason: Obtaining a blood pressure reading is the most critical first step. Severe headache and blurred vision can be symptoms of hypertensive crisis, which is a medical emergency that requires immediate attention to prevent complications such as stroke or organ damage. Checking the blood pressure will help determine if the client's symptoms are due to elevated blood pressure.

Choice C reason: Administering an oral analgesic may provide temporary relief for the headache, but it does not address the potential underlying causes of the symptoms. The priority is to assess and manage any potentially life-threatening conditions.

Choice D reason: Performing a finger stick glucose test is important for monitoring blood glucose levels in a client with diabetes. However, in the context of the severe headache and blurred vision, the immediate concern should be to rule out hypertensive crisis by checking the blood pressure first. Blood glucose can be checked after ensuring the client's blood pressure is not critically high.

Correct Answer is ["8"]

Explanation

Step 1: Convert the client's weight from pounds to kilograms. 176 pounds ÷ 2.2 = 80 kg

Step 2: Determine the total units of insulin needed per hour. 80 kg × 0.1 unit/kg/hour = 8 units/hour

Step 3: Determine the volume of insulin solution needed per hour. (8 units) ÷ (100 units/100 mL) = (8 units) ÷ (1 unit/mL) = 8 mL/hour

So, the nurse should set the infusion pump to deliver 8 mL/hour.

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The nurse is assessing a client who has left ventricular heart failure. Which assessment finding is this client most likely to exhibit?

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Naxlex Comprehensive Predictor Exams

A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is ["8"]

Explanation

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