NCLEX PN COMPREHENSIVE FORM C
The nurse is collecting data on a client with a diagnosis of right-sided heart failure.
The nurse should expect to note which specific characteristic of this condition?
- Dyspnea
- Hacking cough
- Dependent edema
- Crackles on lung auscultation
- Dependent edema
Rationale:
Right-sided heart failure is characterized by signs of systemic congestion that
occur as a result of right ventricular failure, fluid retention, and pressure buildup in
the venous system. Edema develops in the lower legs and ascends to the thighs and
abdominal wall. Other characteristics include jugular (neck vein) congestion,
enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands
and fingers, polyuria at night, and weight gain. Left-sided heart failure produces
pulmonary signs. These include dyspnea, crackles on lung auscultation, and a
hacking cough
The nurse is checking the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. The nurse interprets that the
neurovascular status is which?
- Moderately impaired, and the surgeon should be called
- Normal, caused by increased blood flow through the leg
- Slightly deteriorating, and should be monitored for another hour
- Adequate from an arterial approach, but venous complications are arising
- Normal, caused by increased blood flow through the leg
Rationale:
An expected outcome of surgery is warmth, redness, and edema in the surgical
extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.
A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the
health care provider is going to perform carotid massage. The nurse responds that
this procedure may stimulate which? - Vagus nerve to slow the heart rate
- Vagus nerve to increase the heart rate
- Diaphragmatic nerve to slow the heart rate
- Diaphragmatic nerve to increase the heart rate
- Vagus nerve to slow the heart rate
Rationale:
Carotid sinus massage is one maneuver used for vagal stimulation to decrease a
rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers
are the Valsalva maneuver of inducing the gag reflex and asking the client to strain
or bear down. Medication therapy is often needed as an adjunct to keep the rate
down or maintain the normal rhythm.
A client is admitted to the hospital with possible rheumatic endocarditis. The nurse
should check for a history of which type of infection? - Viral infection
- Yeast infection
- Streptococcal infection
- Staphylococcal infection
- Streptococcal infection
Rationale:
Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of
rheumatic fever, which is a complication of infection with group A β-hemolytic
streptococcal infections. It is frequently triggered by streptococcal pharyngitis.
Options 1, 2, and 4 are incorrect.
A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The
nurse notes that the client’s toes are mottled, and cool and the client verbalizes
some numbness and tingling of the foot. Which interpretation should the nurse
make of these findings? - The boot has not yet dried.
- The boot is controlling leg edema.
- The boot is impairing venous return.
- The boot has been applied too tightly.
- The boot has been applied too tightly.
Rationale:
An Unna boot that is applied too tightly can cause signs of arterial occlusion. The
nurse assesses the circulation in the foot and teaches the client to do the same. The
other options are incorrect interpretations.
A client with angina complains that the anginal pain is prolonged and severe and
occurs at the same time each day, most often in the morning. On further data
collection, the nurse notes that the pain occurs in the absence of precipitating
factors. How should the nurse best describe this type of anginal pain? - Stable angina
- Variant angina
- Unstable angina
- Nonanginal pain
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