A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Shortness of breath while lying down
Jugular venous distention
Right upper quadrant pain
Pitting edema of the lower legs
The Correct Answer is A
A. Shortness of breath while lying down. Shortness of breath when lying down, or orthopnea, is common in left-sided heart failure due to fluid backing up into the lungs, causing pulmonary congestion.
B. Jugular venous distention. Jugular venous distention is more commonly associated with right-sided heart failure due to systemic venous congestion.
C. Right upper quadrant pain. Right upper quadrant pain is associated with liver congestion due to right-sided heart failure, not left-sided heart failure.
D. Pitting edema of the lower legs. Pitting edema is a symptom of right-sided heart failure, as fluid backs up into the peripheral circulation.
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Correct Answer is C
Explanation
A. 25 gtt/min: Calculating the correct rate reveals that this is not the correct answer.
B. 1500 gtt/min: This rate is too high; the calculation does not support this answer.
C. 50 gtt/min: To calculate: (100 mL / 120 min) × 30 gtt/mL = 50 gtt/min.
D. 83 gtt/min: This is too high based on the calculation.
Correct Answer is D
Explanation
A. Barrel chest. A barrel chest is commonly seen in chronic obstructive pulmonary disease (COPD) rather than mitral valve stenosis.
B. Bradycardia. Bradycardia is not typically associated with mitral valve stenosis, as symptoms often include rapid or irregular heartbeat.
C. Clubbing of the fingers. Clubbing is associated with chronic hypoxia, often due to pulmonary conditions, not specifically with mitral valve stenosis.
D. Heart murmur. Mitral valve stenosis causes turbulent blood flow through the narrowed valve, resulting in a characteristic murmur.