Nokea
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
- A. Pedal edema
- B. Enlarged liver
- C. Dyspnea
- D. Neck vein distention
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Left-sided heart failure typically results in pulmonary congestion, leading to symptoms like dyspnea due to fluid accumulation in the lungs. Pedal edema (A) is more common in right-sided heart failure. Enlarged liver (B) is a sign of right-sided heart failure as well. Neck vein distention (D) is indicative of right-sided heart failure due to increased right atrial pressure. The focus in left-sided heart failure is on pulmonary symptoms, making dyspnea the most relevant manifestation.
You may also like to solve these questions
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag, which of the following actions should the nurse take?
- A. Encourage the client to unseat every 2 hr
- B. Apply a cold compress to the suprapubic area
- C. Secure the urinary catheter to the upper left quadrant of the clients abdomen
- D. Use 0.9% sodium chloride to perform an intermittent bladder irrigation
Correct Answer: D
Rationale: The correct answer is D: Use 0.9% sodium chloride to perform an intermittent bladder irrigation. In this scenario, the client is experiencing bladder spasms and a scant amount of fluid in the drainage bag, indicating a potential blockage or clot in the catheter. Performing an intermittent bladder irrigation with 0.9% sodium chloride can help to clear the catheter and improve urine flow. This intervention helps prevent further complications such as urinary retention or infection. Encouraging the client to unseat or applying a cold compress may not address the underlying issue of catheter blockage. Securing the catheter to the upper left quadrant does not directly address the current problem and may not improve urine flow.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
- A. Distended jugular veins.
- B. Increased blood pressure.
- C. Decreased blood pressure.
- D. Pitting, dependent edema.
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure. Dehydration leads to a decrease in blood volume, causing a drop in blood pressure. As a result, the body tries to conserve fluids, leading to decreased urine output and concentrated urine. Distended jugular veins (A) are more indicative of heart failure. Increased blood pressure (B) is not typically associated with dehydration. Pitting, dependent edema (D) is a sign of fluid overload, not dehydration.
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
- A. Hyperalbuminemia
- B. Proteinuria
- C. Decreased serum lipid levels
- D. Decreased coagulation
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to the loss of protein in the urine, specifically albumin. Hyperalbuminemia (choice A) is incorrect as albumin is lost in the urine. Decreased serum lipid levels (choice C) are incorrect because nephrotic syndrome is associated with hyperlipidemia due to altered lipid metabolism. Decreased coagulation (choice D) is incorrect as nephrotic syndrome is actually associated with a hypercoagulable state due to loss of anticoagulant proteins in the urine.
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding, leading to occult blood in the stool. Monitoring stool for occult blood helps in detecting any gastrointestinal bleeding early. Serum calcium (A) is not typically affected by long-term ibuprofen use. Fasting blood glucose (C) is not directly related to ibuprofen use. Urine for white blood cells (D) is not relevant in this scenario.
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Phlebitis
Correct Answer: B
Rationale: The correct answer is B: Infection. When IV tubing is kinked, it can lead to a backflow of urine from the catheter into the tubing, increasing the risk of contamination and subsequent urinary tract infection. Additionally, when the urinary catheter bag is lying next to the client in bed, there is a higher chance of accidental contamination. Infections can lead to serious complications and require prompt intervention. Neurogenic bladder (A) is related to nerve damage affecting bladder control, not directly related to the current situation. Skin breakdown (C) may occur due to prolonged contact with urine but is not the immediate concern here. Phlebitis (D) is inflammation of a vein, not directly linked to the urinary catheter issue.