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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increasing fluids to maintain BP: While staying well-hydrated is generally beneficial for overall health and blood pressure management, increasing fluids is not the primary intervention for dizziness associated with alpha-adrenergic blockers. Alpha-blockers can cause orthostatic hypotension, which may lead to dizziness upon standing, especially if rising quickly.
B. Taking medication first thing in the morning: Taking medication in the morning is a common recommendation for many medications, including some antihypertensive drugs. However, for alpha-adrenergic blockers that can cause orthostatic hypotension, timing of medication administration is not the primary concern in addressing dizziness.
C. Stopping medication if dizziness persists: Abruptly stopping medication without consulting a healthcare provider is not recommended, especially for antihypertensive medications. It's important for clients to follow their prescribed treatment plan and communicate any side effects or concerns to their healthcare provider for appropriate management.
D. Rising slowly from a lying or sitting position: This is the correct emphasis for the nurse. Alpha-adrenergic blockers can cause orthostatic hypotension, a drop in blood pressure upon standing, which can lead to dizziness or lightheadedness. To minimize this risk, the client should be advised to rise slowly from lying down or sitting to standing positions. This gradual movement helps the body adjust to changes in blood pressure more effectively.
Correct Answer is B
Explanation
A. When the client states he is ready to start the infusion:
While it's important to consider the client's readiness and cooperation, the timing of the infusion should not solely depend on the client's statement. The priority is to start the infusion promptly after receiving the packed red blood cells (PRBCs) from the blood bank to ensure their safety and effectiveness.
B. As soon as the nurse can prepare the client and the administration set:
This choice is the correct answer. After receiving the unit of PRBCs from the blood bank at 1130, the nurse should begin the infusion as soon as possible after preparing the client (ensuring the correct patient, verifying the blood type compatibility, obtaining informed consent, etc.) and the administration set (priming the IV tubing, checking for any leaks, etc.). Prompt administration helps prevent delays that could compromise the quality of the blood product.
C. 2 hours after obtaining blood from the blood bank:
Waiting for 2 hours before starting the infusion is too long and could exceed the recommended timeframe for administering PRBCs after obtaining them from the blood bank. Delaying the infusion for such an extended period could impact the viability and safety of the blood product.
D. When the client has finished eating lunch:
The timing of the client's meal is not a factor in determining when to start the infusion of PRBCs. While it's generally important for the client to have adequate nutrition and hydration, the priority is to administer the blood product promptly after preparation to ensure its efficacy and safety, rather than waiting for unrelated factors such as meal times.
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