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The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Edema

Shortness of breath

Increase in appetite

Extreme weight loss

Jugular vein distended (enlarged)

Question Solution

Correct Answer : A,B,E

A. Edema is a common finding in heart failure due to fluid retention.

B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.

C. Increased appetite is not typical in heart failure; decreased appetite is more common.

D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.

E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.

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A. The client is currently febrile with an oral temperature of 101.2°F B. The client is mildly anxious about their condition. C. The client is reporting feeling nauseated D. The client's pain rated 8 out of 10 on a numerical scale E. The client is asking questions about their health status.

Correct Answer is ["A","C","D"]

Explanation

A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.

B. Mild anxiety may not require postponement, as it can be addressed during teaching.

C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.

D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.

E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.

A. Have client use the incentive spirometer every hour B. Help client dangle legs off the side of the bed C. Encourage the client to ambulate as soon as possible D. Keep the client in bed with knees elevated E. Limit the amount of fluid the client drinks

Correct Answer is B

Explanation

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.

B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.

C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.

D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.

E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

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The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

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Correct Answer is ["A","C","D"]

Explanation

Correct Answer is B

Explanation

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Take full exam for free The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

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Explanation

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The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.