Which disorder would the nurse recognize as the likely cause of right heart failure (cor pulmonale)?
Upper GI bleeding
Chronic obstructive pulmonary disease (COPD)
Liver failure
Renal failure
The Correct Answer is B
Choice A reason: Upper GI bleeding is not a direct cause of right heart failure (cor pulmonale). While severe GI bleeding can lead to other complications such as anemia or shock, it does not typically result in cor pulmonale.
Choice B reason: Chronic obstructive pulmonary disease (COPD) is a primary cause of cor pulmonale. COPD leads to chronic hypoxia, which increases pressure in the pulmonary arteries (pulmonary hypertension). The right ventricle of the heart must work harder to pump blood through these high-pressure arteries, eventually leading to right heart failure.
Choice C reason: Liver failure can lead to various systemic complications such as fluid imbalance and electrolyte disturbances, but it is not a direct cause of right heart failure (cor pulmonale). Cor pulmonale is specifically related to pulmonary conditions that increase right ventricular workload.
Choice D reason: Renal failure, while serious and capable of causing cardiovascular complications due to fluid overload and hypertension, is not typically linked to the development of cor pulmonale. The primary cause of cor pulmonale is chronic lung disease like COPD, which directly affects the pulmonary vasculature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.
Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.
Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.
Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.
Correct Answer is ["A","D","F"]
Explanation
Choice A reason: An oxygen mask is essential for providing supplemental oxygen to the patient, especially if they experience respiratory distress or decreased oxygen saturation following a seizure. Ensuring adequate oxygenation is a priority in post-seizure care.
Choice B reason: A nasogastric tube may be used in specific situations for feeding or medication administration, but it is not routinely necessary for all patients treated for status epilepticus.
Choice C reason: A urinary catheter is used for managing urinary output, particularly in patients with retention or incontinence issues, but it is not immediately required for all patients post-status epilepticus.
Choice D reason: Suction set-up is necessary for maintaining the patient's airway and preventing aspiration, particularly if the patient has excessive secretions or vomits after a seizure. Suction equipment allows the nurse to quickly clear the airway and ensure the patient can breathe effectively.
Choice E reason: Tongue blades are not recommended for seizure management as they can cause injury. Historically, there was a misconception about using tongue blades to prevent tongue biting during seizures, but this practice is now discouraged due to the risk of oral injury.
Choice F reason: Side rail pads are important for protecting the patient from injury during potential future seizures. Padded side rails help prevent trauma from hitting the bed rails during convulsions and provide a safer environment for the patient.
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