The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Ascending edema

The client has no desire to eat.

The client sleeps on three pillows at night.

The client has a five pound weight gain.

Answer and Explanation

The Correct Answer is C

A. Ascending edema:

Ascending edema, also known as dependent edema, is typically associated with right-sided heart failure rather than left-sided heart failure. In right-sided heart failure, the heart's ability to pump blood to the lungs for oxygenation is compromised, leading to fluid backup in the systemic circulation. This fluid accumulates in the dependent areas of the body, such as the lower extremities (legs and ankles), causing swelling that can ascend upwards if left untreated. However, ascending edema is not a characteristic finding in left-sided heart failure, where pulmonary congestion and orthopnea are more common manifestations.

B. The client has no desire to eat:

While decreased appetite can occur in heart failure due to various factors such as fluid retention, abdominal bloating, or medication side effects, it is not a specific hallmark of left-sided heart failure. Symptoms such as fatigue, dyspnea (shortness of breath), orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (PND) are more commonly associated with left-sided heart failure. These symptoms result from the impaired function of the left ventricle, leading to pulmonary congestion and inadequate oxygenation.

C. The client sleeps on three pillows at night:

This choice is the correct answer. Sleeping on three pillows at night is a classic manifestation of orthopnea, a condition commonly seen in left-sided heart failure. Orthopnea refers to difficulty breathing while lying flat, which is alleviated by elevating the head and upper body with multiple pillows or sleeping in a semi-upright position. Orthopnea occurs due to the redistribution of fluid from the legs and lower body to the lungs when lying down, resulting in pulmonary congestion and respiratory distress.

D. The client has a five-pound weight gain:

Weight gain is a common symptom of fluid retention in heart failure; however, a specific weight gain of five pounds alone may not be indicative of left-sided heart failure without considering other clinical signs and symptoms. In heart failure, weight gain is often associated with fluid overload, which can lead to edema, dyspnea, orthopnea, and other signs of congestion. It's important to assess the client comprehensively for fluid status, including evaluating for edema, respiratory symptoms, and changes in weight over time, to determine the underlying cause of weight gain.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Notify the blood bank of the discrepancy:

This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.

B. Administer the blood as ordered:

This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.

C. Complete an incident report:

Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.

D. Contact the provider for further orders:

Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.

Correct Answer is ["1712.32"]

Explanation

To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:

1,000 mL 0.9% sodium chloride IV (no conversion needed)

One 6-oz cup of coffee:

6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL

6 oz of water:

6 oz * 29.5735 = approximately 177.44 mL

One 180-mL bowl of soup (no conversion needed)

3 oz of flavored gelatin:

3 oz * 29.5735 = approximately 88.72 mL

3 oz of ice cream:

3 oz * 29.5735 = approximately 88.72 mL

Now, let's add up all the volumes:

1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL

Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.

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The nurse is assessing a client with left-sided heart failure. What would the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is ["1712.32"]

Explanation

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