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","C","D","E"]

Explanation

A. Take the medication with milk to increase absorption:

This statement is incorrect. Taking ferrous sulfate with milk or dairy products is not recommended as they can decrease iron absorption. It's advisable to take iron supplements with water or juice, preferably on an empty stomach or with a small amount of food.

B. Take the medication on an empty stomach:

This statement is partially correct. While taking ferrous sulfate on an empty stomach can enhance absorption, some individuals may experience gastrointestinal discomfort or irritation. Therefore, it's often recommended to take iron supplements with a small amount of food to minimize potential side effects.

C. Eat foods high in fiber while on this medication:

This statement is generally correct. Consuming foods high in fiber can help prevent constipation, which is a common side effect of iron supplements. Including fiber-rich foods in the diet, such as fruits, vegetables, whole grains, and legumes, can promote regular bowel movements.

D. Report stools that are dark in color immediately:

This statement is correct. Dark or black stools can indicate the presence of digested blood, which may occur due to iron supplementation. It's important to report such changes to the healthcare provider promptly for further evaluation.

E. Eating citrus fruit and juices are recommended with meals:

This statement is correct. Citrus fruits and juices, such as oranges, grapefruits, and lemon juice, contain vitamin C, which can enhance iron absorption. Consuming vitamin C-rich foods or drinks along with iron supplements can help improve iron uptake by the body.

A. Weigh yourself once a week. B. Drink 3 liters of fluid per day. C. Engage in exercise daily. D. Restrict dietary potassium.

Correct Answer is C

Explanation

A. Weigh yourself once a week:

This is an important part of heart failure management as weight gain can indicate fluid retention, a common symptom of heart failure. The nurse should instruct the client to weigh themselves at the same time of day, using the same scale, and wearing similar clothing each time. Any sudden weight gain should be reported to the healthcare provider promptly.

B. Drink 3 liters of fluid per day:

This option is not appropriate for most heart failure patients, especially those with fluid retention issues. Fluid intake should be monitored and restricted based on the individual's condition and healthcare provider's recommendations. Consuming too much fluid can exacerbate fluid retention and worsen heart failure symptoms.

C. Engage in exercise daily:

Exercise is generally recommended for heart failure patients, but the type, intensity, and frequency of exercise should be tailored to the individual's condition. The nurse should encourage the client to engage in regular physical activity as tolerated, following a structured exercise plan approved by their healthcare provider. Activities like walking, cycling, or water aerobics can be beneficial for heart health.

D. Restrict dietary potassium:

This option is not typically included in lifestyle modifications for heart failure unless the client has specific potassium-related issues or is taking medications that require potassium restriction. Potassium is an important electrolyte for heart function, and most heart failure patients are advised to consume a balanced diet with moderate potassium intake, unless otherwise directed by their healthcare provider.

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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 client is prescribed ferrous sulfate 325 mg BID. What education should the nurse provide about this medication? (Select All that Apply.)

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

Explanation

The nurse is teaching a client about lifestyle modifications after a heart failure diagnosis. What will be included in the teaching?

Correct Answer is C

Explanation

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