Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?
Enlarged liver and peripheral edema.
Crackles in the lungs.
Dry hacking cough.
Altered mentation with pinpoint pupils.
The Correct Answer is A
Choice A rationale
Enlarged liver (hepatomegaly) and peripheral edema are common clinical manifestations of right heart failure (RHF). RHF leads to congestion of systemic circulation, causing fluid accumulation in the liver and peripheral tissues.
Choice B rationale
Crackles in the lungs are more commonly associated with left-sided heart failure, where fluid backs up into the pulmonary circulation, leading to pulmonary edema.
Choice C rationale
A dry hacking cough is not a typical symptom of right heart failure. It is more commonly associated with respiratory conditions such as asthma or bronchitis.
Choice D rationale
Altered mentation with pinpoint pupils is not a characteristic of right heart failure. These symptoms are more indicative of neurological conditions or opioid overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Poor blood glucose control is a significant factor in delayed wound healing in patients with diabetes. Hyperglycemia impairs various aspects of the immune response, reduces blood flow, and increases the risk of infection, all of which contribute to delayed healing.
Choice B rationale
Inadequate protein intake can also contribute to delayed wound healing. Protein is essential for the repair and regeneration of tissues, and a deficiency can impair the body’s ability to heal wounds effectively.
Choice C rationale
Peripheral neuropathy, a common complication of diabetes, can lead to decreased sensation in the feet, making it more likely for injuries to go unnoticed and untreated. This can result in chronic wounds and delayed healing.
Choice D rationale
All of the above factors—poor blood glucose control, inadequate protein intake, and peripheral neuropathy—can contribute to delayed healing of foot ulcers in patients with diabetes. Each of these factors plays a role in the complex process of wound healing and can hinder the body’s ability to repair itself.
Correct Answer is B
Explanation
Choice A rationale
Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.
Choice B rationale
Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.
Choice C rationale
Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.
Choice D rationale
Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.
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