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."

Answer and Explanation

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).

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Correct Answer is B

Explanation

A. This option is not directly related to preventing exacerbations in COPD. While managing fluid intake may be important for individuals with certain cardiovascular or renal conditions, it is not a recognized strategy for preventing COPD exacerbations.
B. Influenza vaccination is highly recommended for individuals with COPD. Respiratory infections, such as influenza (flu), can trigger exacerbations in COPD. By receiving an annual influenza vaccine, the client can reduce the risk of developing influenza-related exacerbations and complications.
C. Pursed-lip breathing is a breathing technique that can help improve ventilation and decrease the work of breathing for individuals with COPD. It can be beneficial during exacerbations or episodes of dyspnea (shortness of breath). While it does not directly prevent exacerbations, it is a useful technique to manage symptoms and potentially reduce the severity of exacerbations.
D. The tripod position, where a person leans forward with hands supported on their knees or another surface, can help COPD patients during exacerbations by allowing better chest expansion and improving breathing mechanics. It can relieve dyspnea and help stabilize breathing. While it does not prevent exacerbations, it is a helpful technique during episodes of increased respiratory distress.

A. Leave the affected area open to air when you are at home. B. Limit ice-pack application to the area to 20 minutes at a time. C. Lubricate the area with an alcohol-based lotion. D. You may use aloe vera gel on the affected skin. E. Clean the area with betadine to prevent infection.

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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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?

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