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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Numbness and tingling in the left hand could indicate compromised blood flow or nerve damage, potentially due to the arterial line, requiring immediate assessment and intervention.

B. Slight bloody drainage is a common finding and typically does not require immediate action.

C. A dressing beginning to lift should be addressed to maintain a sterile environment but is not an emergency.

D. Slight redness at the insertion site may indicate mild irritation or early signs of infection, but it does not require immediate intervention compared to the potential vascular or nerve compromise suggested by numbness and tingling.

A. Call the provider for a stat DNR order. B. Start CPR and call the emergency response team. C. Seek immediate help from the risk manager. D. Respect the family's wishes and do nothing.

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.

View Question and Answer

A nurse is caring for a client in the emergency department (ED).

<div id="exhibits">Exhibits</div>

The nurse is planning care for the client. For each potential prescription, indicate whether it is an anticipated (high priority), nonessential (low priority), contraindicated(unrelated).

Select one or more in each option.

View Question and Answer

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Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action?

Correct Answer is A

Explanation

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best?

Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)

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