Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)
Crackles upon auscultation of the lungs
Hepatomegaly
Jugular venous distention
Orthopnea
Peripheral edema
Correct Answer : B,C,E
A. Crackles are more commonly associated with left ventricular failure, which leads to pulmonary congestion.
B. Hepatomegaly, or an enlarged liver, is a sign of right ventricular failure due to blood backing up in the systemic circulation.
C. Jugular venous distention is a classic sign of right ventricular failure as blood accumulates in the venous system.
D. Orthopnea, or difficulty breathing while lying down, is more indicative of left ventricular failure.
E. Peripheral edema is a hallmark of right ventricular failure, resulting from increased venous pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While lowering BP to 120/80 may be an ultimate goal, it is not the initial target in a hypertensive emergency.
B. Rapid reduction in blood pressure can cause hypoperfusion of vital organs such as the brain, heart, and kidneys, leading to ischemic injury. The aim is to reduce the BP gradually to prevent these complications.
C. IV antihypertensive medications generally have a rapid onset, not a slow one.
D. While gradual reduction is important, it is not done to allow rest but to protect organ perfusion.
Correct Answer is B
Explanation
A. There is no time to wait for a DNR order in an emergency; immediate action is needed.
B. Without a written DNR order, the nurse is legally and ethically obligated to initiate CPR and call the emergency response team to attempt to save the client’s life.
C. Contacting the risk manager is not an immediate action that would benefit the patient in this emergency situation.
D. The family’s wishes cannot be respected in this scenario without a formal DNR order in place; thus, the nurse must perform CPR.
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