Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?
A. Dependent edema
Dependent edema is more likely to be seen in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
B. Frothy sputum
Frothy sputum is a sign of left-sided heart failure, due to the pulmonary congestion and impaired gas exchange. The sputum may be pink-tinged or blood-streaked, indicating pulmonary edema.
C. Nocturnal polyuria
Nocturnal polyuria is not a specific finding of left-sided heart failure, but it may occur in clients who have renal impairment, diabetes mellitus, or diuretic therapy.
D. Jugular distention
Jugular distention is another sign of right-sided heart failure, due to the increased central venous pressure and backward flow of blood into the superior vena cava. It is visible as a bulging of the neck veins, especially when the client is in a semi-Fowler's position.
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Full Explanation
Frothy sputum is a sign of left-sided heart failure, due to the pulmonary congestion and impaired gas exchange. The sputum may be pink-tinged or blood-streaked, indicating pulmonary edema.
a. Dependent edema is more likely to be seen in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
c. Nocturnal polyuria is not a specific finding of left-sided heart failure, but it may occur in clients who have renal impairment, diabetes mellitus, or diuretic therapy.
d. Jugular distention is another sign of right-sided heart failure, due to the increased central venous pressure and backward flow of blood into the superior vena cava. It is visible as a bulging of the neck veins, especially when the client is in a semi-Fowler's position.
Similar Questions
A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?
A. "Apply ice packs to your legs."
"Apply ice packs to your legs." is not appropriate, as ice packs can cause vasoconstriction and impair blood flow to the legs, worsening the condition.
B. "Place your legs in a dependent position while in bed."
"Place your legs in a dependent position while in bed." is not advisable, as dependent position can increase venous pressure and fluid accumulation in the legs, leading to edema, pain, and skin breakdown.
C. "Remain on bed rest."
"Remain on bed rest." is not necessary, as bed rest can reduce muscle contraction and impair venous return. The client should be encouraged to perform regular exercise, such as walking, to enhance circulation and prevent complications.
D. "Use elastic stockings."
Using elastic stockings is an effective way to improve venous return and prevent edema, stasis, and ulceration in clients who have venous insufficiency. The stockings should be applied before getting out of bed and worn throughout the day.
Full Explanation
Using elastic stockings is an effective way to improve venous return and prevent edema, stasis, and ulceration in clients who have venous insufficiency. The stockings should be applied before getting out of bed and worn throughout the day.
"Apply ice packs to your legs." is not appropriate, as ice packs can cause vasoconstriction and impair blood flow to the legs, worsening the condition.
"Place your legs in a dependent position while in bed." is not advisable, as dependent position can increase venous pressure and fluid accumulation in the legs, leading to edema, pain, and skin breakdown
"Remain on bed rest." is not necessary, as bed rest can reduce muscle contraction and impair venous return. The client should be encouraged to perform regular exercise, such as walking, to enhance circulation and prevent complications.
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
A. Place a moist heating pad under the client's feet.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
B. Increase the client's oral fluid intake.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
C. Obtain a pair of slipper-socks for the client.
Obtaining a pair of slipper-socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
D. Rub the client's feet briskly for several minutes.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
Full Explanation
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
A nurse is providing teaching to a client who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse include?
A. Take 1 capsule at the onset of anginal pain.
Taking 1 capsule at the onset of anginal pain is not appropriate, as nitroglycerin oral, sustained-release capsules are not meant for acute episodes of angina, but for long-term prevention and management. The client should use a fast-acting form of nitroglycerin, such as sublingual tablets or spray, to relieve anginal pain.
B. Take the medication with meals.
Taking the medication with meals is not necessary, as nitroglycerin oral, sustained-release capsules can be taken with or without food. However, the client should take the medication at regular intervals and around the same time each day.
C. Swallow the capsules whole.
Swallowing the capsules whole is the correct way to take nitroglycerin oral, sustained-release capsules, as they are designed to release the medication slowly and steadily over time. The client should not crush, chew, or open the capsules, as this can alter the absorption and effectiveness of the medication.
D. Stop taking the medication if side effects are troublesome.
Stopping taking the medication if side effects are troublesome is not advisable, as nitroglycerin oral, sustained- release capsules can cause withdrawal symptoms and rebound angina if discontinued abruptly. The client should consult with the provider before stopping or changing the dose of the medication. The client should also report any severe or persistent side effects, such as headache, dizziness, hypotension, or tachycardia.
Full Explanation
Swallowing the capsules whole is the correct way to take nitroglycerin oral, sustained-release capsules, as they are designed to release the medication slowly and steadily over time. The client should not crush, chew, or open the capsules, as this can alter the absorption and effectiveness of the medication.
Taking 1 capsule at the onset of anginal pain is not appropriate, as nitroglycerin oral, sustained-release capsules are not meant for acute episodes of angina, but for long-term prevention and management. The client should use a fast-acting form of nitroglycerin, such as sublingual tablets or spray, to relieve anginal pain.
Taking the medication with meals is not necessary, as nitroglycerin oral, sustained-release capsules can be taken with or without food. However, the client should take the medication at regular intervals and around the same time each day.
Stopping taking the medication if side effects are troublesome is not advisable, as nitroglycerin oral, sustained-release capsules can cause withdrawal symptoms and rebound angina if discontinued abruptly. The client should consult with the provider before stopping or changing the dose of the medication. The client should also report any severe or persistent side effects, such as headache, dizziness, hypotension, or tachycardia.