The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?
"I feel short of breath when I lie down flat."
"The sputum I have been coughing up is pink."
"The nurse I had yesterday said she could hear fluid in my lungs."
"I feel like fluid has been building up in my abdominal area."
The Correct Answer is D
A. This symptom is consistent with orthopnea, which is common in left-sided heart failure rather than right-sided heart failure. In orthopnea, patients experience shortness of breath when lying flat because fluid accumulates in the lungs due to impaired left ventricular function.
B. Pink-tinged or blood-tinged sputum, known as hemoptysis, can occur in left-sided heart failure due to pulmonary congestion and elevated pressures in the pulmonary circulation. This symptom is not typically associated with right-sided heart failure.
C. This finding suggests pulmonary congestion, which is more indicative of left-sided heart failure. In left- sided heart failure, fluid backs up into the lungs, leading to crackles or rales on auscultation.
D. This statement is consistent with right-sided heart failure. In right-sided heart failure, the right ventricle fails to effectively pump blood into the pulmonary circulation, causing fluid to back up into the venous system. This can lead to peripheral edema (such as in the legs and abdomen) and abdominal distension due to ascites (fluid accumulation in the peritoneal cavity).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypernatremia can indicate dehydration or other electrolyte imbalances. Furosemide can further affect electrolyte balance, especially sodium and potassium. However, this sodium level is only slightly elevated and may not necessarily require immediate action regarding furosemide administration.
B. Furosemide is a diuretic that can further decrease blood pressure due to its effects on fluid volume reduction. Administering it to a patient with already low blood pressure could potentially lead to significant hypotension and compromise perfusion to vital organs.
C. While incontinence itself may not directly contraindicate furosemide administration, it could indicate underlying issues such as bladder dysfunction or fluid overload that need further evaluation. This finding alone would not necessarily require holding the medication, but it warrants further assessment and consideration in the clinical context.
D. Normal serum potassium levels typically range from 3.5-5.0 mEq/L. A level of 5.3 mEq/L indicates hyperkalemia (elevated potassium). While this potassium level is mildly elevated, it would not be a reason on its own to hold furosemide. Monitoring potassium levels closely and potentially adjusting potassium
Correct Answer is ["A","D"]
Explanation
A. Allowing the affected skin to be exposed to air can help in promoting healing and preventing further irritation. However, it's essential to ensure the environment is clean and that the area is protected from friction and contamination.
B. Ice packs should be avoided as they can cause further irritation to the radiated skin, and alcohol- based lotions can be drying and may exacerbate skin reactions.
C. Alcohol-based lotions can be drying and irritating to sensitive, radiation-treated skin. It's preferable to use gentle, non-alcohol-based moisturizers or barrier creams that are specifically designed for sensitive skin. These can help soothe the skin and prevent excessive dryness and irritation.
D. Aloe vera gel is known for its soothing and moisturizing properties, which can help alleviate discomfort and promote healing of radiation-damaged skin. It is gentle and generally well-tolerated by most individuals.
E. Betadine (povidone-iodine) can be too harsh for radiation-damaged skin and may further irritate the area. Gentle cleansing with mild soap and water is recommended to keep the area clean and minimize the risk of infection.
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