The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

"How many pillows do you sleep on mister"

"Do you have chest pain when you walk up the steps?"

"Do you find that your rings and shoes feel tight at the end of the day?"

"How many times do you get up to void at night?"

Answer and Explanation

The Correct Answer is A

A.   This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B.   Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C.   Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D.   Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.

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Correct Answer is B

Explanation

A. Increased risk for cardiac dysrhythmias: While hyponatremia can sometimes contribute to cardiac dysrhythmias, it's not the primary concern in this case. The main issue is fluid overload.
B. Hyponatremia, or low sodium levels, is often associated with heart failure. In this condition, the heart's reduced pumping ability leads to fluid retention, which dilutes the sodium concentration in the blood.
C. Imbalance in the sodium-potassium pump: While this can contribute to electrolyte imbalances, it's not the direct cause of hyponatremia in heart failure.
D. Acute renal failure: While heart failure can lead to acute kidney injury, hyponatremia is primarily a result of fluid overload rather than kidney dysfunction.

A. Cyanosis B. Petechiae C. Epistaxis D. Hematuria

Correct Answer is A

Explanation

A. Cyanosis, or a bluish discoloration of the skin, occurs when there is insufficient oxygen in the blood, which can result from decreased perfusion due to clotting in DIC. It is a sign of poor oxygenation and perfusion.
B. While petechiae (small red or purple spots) are a common manifestation of DIC due to microvascular clotting and bleeding, they are not a sign of decreased perfusion.
C. Epistaxis (nosebleeds) is another bleeding manifestation of DIC but is not indicative of decreased perfusion, which is more closely related to cyanosis.
D. Hematuria (blood in the urine) can occur in DIC due to clotting in the kidneys or urinary tract. However, it is more related to bleeding than to decreased perfusion.

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The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

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