Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)
Crackles upon auscultation of the lungs
Hepatomegaly
Jugular venous distention
Orthopnea
Peripheral edema
Correct Answer : B,C,E
Rationale:
A. Crackles are more commonly associated with left ventricular failure, which leads to pulmonary congestion.
B. Hepatomegaly, or an enlarged liver, is a sign of right ventricular failure due to blood backing up in the systemic circulation.
C. Jugular venous distention is a classic sign of right ventricular failure as blood accumulates in the venous system.
D. Orthopnea, or difficulty breathing while lying down, is more indicative of left ventricular failure.
E. Peripheral edema is a hallmark of right ventricular failure, resulting from increased venous pressure.
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Correct Answer is D
Explanation
Rationale:
A. Documentation of waveform values is important but does not directly enhance patient safety during monitoring.
B. Limiting the pressure tubing length can help maintain accuracy, but it is not the primary safety measure.
C. Zero referencing is crucial for accurate readings, but it must be done in conjunction with ensuring alarms are active.
D. Ensuring that alarm limits are turned on and appropriately set is the best safety measure to immediately alert the nurse to any critical changes in the patient's status.
Correct Answer is A
Explanation
Rationale:
A. Clustering nursing activities helps to minimize interruptions, allowing the patient to have longer periods of uninterrupted rest, which is essential for recovery and reducing sensory disturbances from sleep deprivation.
B. Silencing alarms could compromise patient safety and is not recommended.
C. Administering sedatives or opioids should be done cautiously and is not a first-line approach for promoting sleep, especially if non-pharmacological methods can be effective.
D. While reducing nighttime assessments may help with sleep, it is not always feasible and should be balanced with the need for monitoring the patient’s condition.