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. Fluticasone is a corticosteroid inhaler used for maintenance therapy to reduce inflammation in the airways over time. It is not a rescue medication for acute symptoms. Clients with COPD should use short-acting bronchodilators (such as albuterol) as their first-line treatment for relieving acute symptoms like shortness of breath or wheezing.
B. This statement is correct. Fluticasone is a corticosteroid medication that, when inhaled, can increase the risk of developing oral candidiasis (thrush). Clients should be instructed to rinse their mouth with water and spit after using the inhaler to minimize this risk. Inspecting the mouth daily for signs of white patches, soreness, or difficulty swallowing is important. If thrush develops, clients may need antifungal treatment.
C. This statement is not necessary for fluticasone inhaler use. Fluticasone is not known to significantly affect heart rate. Monitoring heart rate before each dose is more relevant for medications that can cause changes in heart rate, such as bronchodilators (e.g., beta-agonists). However, clients should monitor for symptoms like palpitations or rapid heart rate and report them to their healthcare provider.
D. Fluticasone is a maintenance medication that should be taken regularly as prescribed, regardless of symptoms. Skipping doses can lead to worsening of COPD symptoms and exacerbations. Clients should adhere to the prescribed dosing schedule to achieve optimal control of their condition.
Correct Answer is A
Explanation
A. By surrounding themselves with familiar items, such as photos, favorite objects, or comforting decor from their previous home, the resident can feel more at ease and connected to their past. This approach helps in creating a more homelike atmosphere and reducing feelings of disorientation and stress associated with the move.
B. Isolating the resident and encouraging avoidance of social interactions can exacerbate feelings of loneliness, isolation, and anxiety. Avoiding social interactions may prolong feelings of stress and hinder adaptation to the new living situation.
C. While it's important to manage the frequency and timing of visits to ensure the resident is not overwhelmed, outright restricting visitation hours can be counterproductive. Restricting visitation could increase feelings of isolation and loneliness, which are already common in new residents of long-term care facilities.
D. Using sedative medications should be reserved for situations where non-pharmacological interventions have been unsuccessful and the resident's anxiety or distress is severe and persistent. Sedatives can have side effects, especially in older adults, and should not be the first-line approach for managing relocation stress syndrome.
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