a nurse is assessing a client with right sided heart failure which of the following symptoms would the nurse most likely see in this client a nurse is assessing a client with right sided heart failure which of the following symptoms would the nurse most likely see in this client
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2024 NGN NCLEX RN Test Prep Questions and Answers With Rationale Version 1

1. A client with right-sided heart failure is being assessed by a nurse. Which of the following symptoms would the nurse most likely observe in this client?

Correct answer: B: Coughing and 3+ pitting edema

Rationale: In right-sided heart failure (cor pulmonale), the right side of the heart struggles to pump blood to the lungs. This leads to symptoms related to fluid buildup in the body, such as coughing due to respiratory distress and 3+ pitting edema, commonly seen in the feet and ankles. Weight loss and vomiting (Choice A) are not typical symptoms of right-sided heart failure. Muscle cramps and hyperreflexia (Choice C) are more indicative of electrolyte imbalances or neurological issues. Lethargy and paroxysmal nocturnal dyspnea (Choice D) are commonly associated with left-sided heart failure, not right-sided heart failure.

2. While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?

Correct answer: 10 am, 2 pm, and 6 pm

Rationale: The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.

3. What question must the nurse ask when formulating a nursing diagnosis?

Correct answer: What is the issue that I can solve for this client?

Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.

4. A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?

Correct answer: Fever and rash

Rationale: The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite. Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice C) are not specific signs of RMSP. Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.

5. The client is being prepared for insertion of a pulmonary artery catheter (Swan-Ganz catheter). What information does the client need to know about the purpose of this catheter insertion?

Correct answer: Left ventricular functioning

Rationale: The correct answer is D: Left ventricular functioning. The purpose of inserting a pulmonary artery catheter is to obtain information about left ventricular functioning when the catheter balloon is inflated. Choices A, B, and C are incorrect because while a pulmonary artery catheter can provide information on stroke volume, cardiac output, and venous pressure, its primary purpose is to assess left ventricular function.

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