The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
Internal bleeding.
Right-sided heart failure.
Cardiac tamponade.
Left ventricular dysfunction.
The Correct Answer is B
A. Internal bleeding may present with symptoms such as hypotension, tachycardia, and signs of blood loss, but it typically does not cause pitting edema or jugular venous distention.
B. Right-sided heart failure can cause systemic venous congestion, leading to pitting edema of the lower extremities and jugular venous distention due to increased central venous pressure.
C. Cardiac tamponade presents with Beck's triad (hypotension, distended neck veins, muffled heart sounds) and is typically more acute in onset compared to the gradual development of symptoms seen in right-sided heart failure.
D. Left ventricular dysfunction primarily causes symptoms of pulmonary congestion, such as dyspnea, orthopnea, and crackles, rather than pitting edema and jugular venous distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is essential in the immediate management of a client with sudden, severe headache and neurological deficits suggestive of stroke. Time- sensitive interventions, such as IV fibrinolytic therapy, may be indicated if the client meets criteria for treatment.
B. Administering aspirin to prevent further clot formation and platelet clumping is contraindicated in the acute management of a suspected stroke until hemorrhagic stroke is ruled out.
C. Verifying prescribed laboratory tests include prothrombin time and platelet count is important for assessing coagulation status, but it is not the immediate intervention needed in this situation.
D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority intervention in the acute management of a suspected stroke.
Correct Answer is D
Explanation
A. Auscultating the abdomen for bowel sound activity is important, but the priority is addressing the dehisced and eviscerated wound.
B. Bringing additional sterile dressing supplies is a good idea, but the priority is addressing the dehisced and eviscerated wound.
C. Obtaining a sample of the drainage for laboratory analysis can wait until the client's immediate needs are addressed.
D. Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.
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