a nurse is caring for a client who has right sided heart failure which of the following findings should the nurse expect a nurse is caring for a client who has right sided heart failure which of the following findings should the nurse expect
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ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A nurse is caring for a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: JVD. Jugular venous distention (JVD) is a common finding in right-sided heart failure due to fluid overload. This occurs because the right side of the heart is unable to effectively pump blood, leading to congestion and increased venous pressure, which is manifested as JVD. Choices A, C, and D are incorrect. Peripheral edema (choice A) is more commonly associated with left-sided heart failure. Crackles in the lungs (choice C) are indicative of pulmonary edema, often seen in left-sided heart failure. Hypotension (choice D) is not typically seen in right-sided heart failure, as it is more commonly associated with conditions like shock or severe dehydration.

2. Simple squamous epithelium is an example of a(n)

Correct answer: tissue.

Rationale: Simple squamous epithelium is a type of tissue, not an organ system, organ, or molecule. Tissues are groups of cells that work together to perform a specific function. In this case, simple squamous epithelium is a thin, single layer of flattened cells that line surfaces involved in passive diffusion, such as the alveoli in the lungs or blood vessels. Therefore, the correct answer is 'tissue.' Choices A, B, and D are incorrect as they do not accurately categorize simple squamous epithelium as a tissue.

3. A patient has developed a decubitus ulcer on the coccyx. What defense mechanism is most affected by this homeostatic change?

Correct answer: C

Rationale: In this scenario, a decubitus ulcer on the coccyx indicates a breakdown of the skin's integrity due to prolonged pressure. The skin is the primary defense mechanism of the body against external pathogens. When the skin is compromised, it can lead to infections and other complications. The mucous membrane (Choice A) plays a role in protecting internal surfaces, not the skin. The respiratory tract (Choice B) is involved in breathing and not directly related to the skin's defense. The gastrointestinal tract (Choice D) is responsible for digestion and absorption of nutrients, not the primary defense mechanism against external threats like the skin.

4. A client is about to undergo surgery and is unsure about the procedure despite signing the consent. What should the nurse do?

Correct answer: B

Rationale: When a client expresses doubts about a procedure after signing the consent form, it is crucial to stop the surgery and consult with the surgeon. This is important to ensure that the client's concerns are addressed, and there is a clear understanding of the procedure. Reassuring the client and proceeding with the surgery (choice A) may violate the client's autonomy and right to informed consent. Proceeding with the surgery but documenting the concerns (choice C) is not sufficient as the client's doubts should be resolved before proceeding. Postponing the surgery until further clarification is provided (choice D) may be necessary, but the immediate step should be to consult with the surgeon to address the client's concerns.

5. Which procedure is used to remove excess fluid or air from the pleural space, helping to relieve pressure on the lungs?

Correct answer: A

Rationale: The correct answer is Thoracentesis. Thoracentesis is a procedure specifically designed to remove excess fluid or air from the pleural space in the chest. This process helps to relieve pressure on the lungs and improve breathing. Bronchoscopy (Choice B) is a procedure used to visualize the airways and diagnose lung conditions, not to remove fluid from the pleural space. Chest X-ray (Choice C) is an imaging test that provides a picture of the structures inside the chest, including the lungs, heart, and bones. Arterial blood gas (ABG) test (Choice D) is a blood test that measures the levels of oxygen and carbon dioxide in the blood, providing information about how well the lungs are working, but it does not involve removing excess fluid or air from the pleural space.

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