Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
On examination, the nurse would expect what finding if a client is in right-sided heart failure?
A. Increased jugular venous pressure
Increased jugular venous pressure: Right-sided heart failure often leads to increased jugular venous pressure due to the backup of blood in the systemic venous system.
B. Decreased right-sided volume
Decreased right-sided volume: Right-sided heart failure typically results in increased blood volume in the right heart chambers, not decreased.
C. Decreased stroke volume
Decreased stroke volume: While right-sided heart failure can affect stroke volume, increased jugular venous pressure is a more direct indicator of right-sided heart failure.
D. Decreased central venous pressure
Decreased central venous pressure: Right-sided heart failure usually results in increased, not decreased, central venous pressure.
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Full Explanation
A. Increased jugular venous pressure: Right-sided heart failure often leads to increased jugular venous pressure due to the backup of blood in the systemic venous system.
B. Decreased right-sided volume: Right-sided heart failure typically results in increased blood volume in the right heart chambers, not decreased.
C. Decreased stroke volume: While right-sided heart failure can affect stroke volume, increased jugular venous pressure is a more direct indicator of right-sided heart failure.
D. Decreased central venous pressure: Right-sided heart failure usually results in increased, not decreased, central venous pressure.
Similar Questions
While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?
A. Pitting edema
Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill
Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature
Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses
Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
Full Explanation
A. Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)
A. Rovsing sign
Rovsing sign: This sign involves pain in the right lower quadrant when palpating the left lower quadrant, indicating appendicitis.
B. Obturator sign
Obturator sign: Pain on internal rotation of the hip when the knee is flexed can indicate irritation of the appendix.
C. Murphy sign
Murphy sign: This sign is used to assess for cholecystitis, not appendicitis.
D. Psoas sign
Psoas sign: Pain with extension of the right leg can indicate irritation of the appendix due to the psoas muscle.
Full Explanation
A. Rovsing sign: This sign involves pain in the right lower quadrant when palpating the left lower quadrant, indicating appendicitis.
B. Obturator sign: Pain on internal rotation of the hip when the knee is flexed can indicate irritation of the appendix.
C. Murphy sign: This sign is used to assess for cholecystitis, not appendicitis.
D. Psoas sign: Pain with extension of the right leg can indicate irritation of the appendix due to the psoas muscle.
A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).
A. ST segment
ST segment: Represents the period between ventricular depolarization and repolarization.
B. QRS complex
QRS complex: Represents ventricular depolarization.
C. T wave
T wave: Indicates ventricular repolarization, or relaxation, after the QRS complex.
D. P wave
P wave: Represents atrial depolarization.
Full Explanation
A. ST segment: Represents the period between ventricular depolarization and repolarization.
B. QRS complex: Represents ventricular depolarization.
C. T wave: Indicates ventricular repolarization, or relaxation, after the QRS complex.
D. P wave: Represents atrial depolarization.