The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
Heart failure
Pulmonary embolism
Tension pneumothorax
Cardiac tamponade
The Correct Answer is A
A. Heart failure often presents with dyspnea, crackles (from pulmonary congestion), jugular vein distention, dependent edema, and hepatomegaly due to fluid overload and impaired cardiac output—these are classic signs.
B. Pulmonary embolism typically causes sudden dyspnea, chest pain, and tachypnea but not hepatomegaly or dependent edema.
C. Tension pneumothorax presents with tracheal deviation, absent breath sounds on one side, and hypotension—different from the systemic fluid overload signs described.
D. Cardiac tamponade presents with muffled heart sounds, hypotension, and jugular vein distention (Beck's triad), but it does not cause crackles, hepatomegaly, or peripheral edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ventricular tachycardia presents with wide QRS complexes (usually >0.12 second), and the rhythm is typically regular—not irregular as seen here.
B. Sinus tachycardia has identifiable P waves before each QRS complex and a regular rhythm, which is not the case here.
C. Ventricular fibrillation presents as a chaotic, irregular waveform with no identifiable QRS complexes, resulting in no effective cardiac output—this is more severe than the rhythm described.
D. Atrial fibrillation is characterized by the absence of P waves, irregularly irregular rhythm, wavy baseline (fibrillatory waves), and often a rapid ventricular response, such as the heart rate of 120 bpm observed in this client.
Correct Answer is D
Explanation
A. Ventricular tachycardia is less commonly triggered by suctioning.
B. Sinus tachycardia may occur but is not the most common arrhythmia during suctioning.
C. Supraventricular tachycardia is not typically associated with suctioning.
D. Sinus bradycardia is the most common arrhythmia caused by vagal stimulation during endotracheal suctioning.
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