a client is admitted with a diagnosis of left sided heart failure which assessment finding is most consistent with this diagnosis
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding is most consistent with this diagnosis?

Correct answer: D

Rationale: Orthopnea (D) is most consistent with left-sided heart failure. It is characterized by difficulty breathing when lying flat and is relieved by sitting up or standing. Dependent edema (A), ascites (B), and nocturia (C) are more commonly associated with right-sided heart failure. Dependent edema refers to swelling due to fluid accumulation, ascites is the accumulation of fluid in the peritoneal cavity, and nocturia is the excessive need to urinate during the night, all of which are more indicative of right-sided heart failure.

2. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

3. An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:

Correct answer: D

Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.

4. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?

Correct answer: A

Rationale: The ventrogluteal site is the preferred location for administering large volume IM injections to avoid nerve injury. This site is situated away from major nerves and blood vessels, reducing the risk of complications associated with injecting into other areas. The ventrogluteal site allows for deep muscle penetration and is recommended for injections over 2 mL in volume to ensure proper dispersion and absorption of the medication. Choices B, C, and D are incorrect because the outer upper quadrant of the buttock is not the recommended site for large volume injections, two inches below the acromion process is a location for a deltoid injection, and the vastus lateralis is typically used for smaller volume injections.

5. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

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