You are caring for an 84-year-old male who has just returned from the operating room (OR) after inguinal hernia repair. You note the patient has fluid volume excess from the OR and is at risk for left-sided heart failure
What signs and symptoms indicate left-sided heart failure?
A) Jugular vein distention
B) Right upper quadrant pain
C) Bibasilar fine crackles
D) Dependent edema
Ans: C
Feedback: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
You might also like to view...
Research has shown an increased risk of contracting Neisseria meningitides from respirator secretions during which of the following procedures?
a. providing a complete bed bath c. examining vaginal or rectal secretions b. injecting material into epidural spaces d. inserting a Foley catheter or rectal tube
A patient with histoplasmosis is being treated with itraconazole [Sporanox]. The nurse will teach this patient to report which symptoms?
a. Gynecomastia and decreased libido b. Headache and rash c. Nausea, vomiting, and anorexia d. Visual disturbances
Which nursing intervention would you use to prevent injury in the client receiving oxygen therapy by continuous nasal cannula?
A. Providing mouth care every 8 hours B. Lubricating the lips with water-soluble jelly C. Draining the condensation in the tubing every 2 hours D. Changing the position of the elastic band every 4 hours
The nurse is documenting a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?
A. Monitoring the client's vital signs every hour for 4 hours B. Placing the client in Trendelenburg's position C. Encouraging early ambulation D. Reorienting the client to time and place