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The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?

A.

Internal bleeding.

B.

Right-sided heart failure.

C.

Left ventricular dysfunction.

D.

Cardiac tamponade.

Answer and Explanation

The Correct Answer is B

A. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.  

 

B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.  

 

C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.  

 

D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.


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View Related questions

Correct Answer is B

Explanation

A. Eating a protein snack before exercising can help prevent hypoglycemia, but this may not be necessary for every individual and does not address the overall management of diabetes.

B. Understanding the importance of receiving an influenza vaccine annually is crucial for clients with diabetes, as they are at higher risk for complications from influenza and other infections.

C. While it is important to monitor alcohol consumption, the statement may not indicate full understanding of how alcohol can affect blood glucose levels and the potential need for individualized guidance.

D. While using salt, herbs, and spices can enhance food flavor, it does not specifically address diabetes management, particularly regarding sodium intake for individuals at risk for hypertension.

Correct Answer is B

Explanation

A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.

B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.

C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.

D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.

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