What is the best indication if the client with congestive heart failure is holding excess fluid?

Intake and output

Pitting pedal edema

Crackles in the bases of the lungs

Daily weights

Answer and Explanation

The Correct Answer is D

A. Intake and output:

Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.

B. Pitting pedal edema:

Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.

C. Crackles in the bases of the lungs:

Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.

D. Daily weights:

Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.

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Correct Answer is B

Explanation

A. The development of chronic obstructive pulmonary disease (COPD)

Explanation: The signs and symptoms described, including crackles, orthopnea, S3 heart sound, cough with pink, frothy sputum, and low pulse oximetry, are more indicative of heart failure than COPD.

B. The development of left-sided heart failure

Explanation: This is the correct answer. The signs and symptoms, such as crackles, orthopnea, and cough with pink, frothy sputum, are characteristic of left-sided heart failure. The S3 heart sound is often associated with increased ventricular filling pressures.

C. The development of right-sided heart failure

Explanation: The presented signs and symptoms are more consistent with left-sided heart failure. Right-sided heart failure is often associated with peripheral edema, hepatomegaly, and jugular venous distension.

D. The development of cor pulmonale

Explanation: Cor pulmonale is typically associated with right-sided heart failure due to chronic lung disease. The signs and symptoms described are more indicative of left-sided heart failure.

A. “The test will provide a detailed profile of the heart’s electrical activity.” B. “I will need to start an IV in your arm before the test.” C. “Your throat may be a little sore after the exam.” D. “You will need to refrain from eating and drinking 6-8 hours before this test.”

Correct Answer is A

Explanation

A. "The test will provide a detailed profile of the heart’s electrical activity."

This statement is inappropriate because transesophageal echocardiography (TEE) primarily provides detailed images of the heart's structure, such as the valves and chambers, rather than focusing on the heart's electrical activity. The assessment of electrical activity is typically associated with electrocardiography (ECG or EKG) rather than echocardiography.

B. "I will need to start an IV in your arm before the test."

This statement is appropriate. It is common for medical procedures, including TEE, to require an intravenous (IV) line for administration of medications or fluids during or after the procedure.

C. "Your throat may be a little sore after the exam."

This statement is appropriate. TEE involves inserting a probe through the esophagus, and it is common for patients to experience a sore throat afterward due to the presence of the probe.

D. "You will need to refrain from eating and drinking 6-8 hours before this test."

This statement is appropriate. It is standard practice to ask patients to fast for a specific period before TEE to minimize the risk of complications, such as aspiration, during the procedure.

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What is the best indication if the client with congestive heart failure is holding excess fluid?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally: 3 pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

Correct Answer is B

Explanation

A client with a complex cardiac history is scheduled for transesophageal echocardiography. Which of the following statements, if made by the nurse, is inappropriate?

Correct Answer is A

Explanation

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