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1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse expect?
a. Bradycardia- more tachycardia cuz of a failing ventricle , SNS is activated to compensate .
b. Flushed skin- duskly it wIll look like
c. Frothy sputum-Left sided- can be blood tinged
d. Jugular vein distention→ Right
Rationale: ATI MS: pg. 198 ch 32 pdf
Left side: dyspnea, orthopnea, fatigue, pulmonary congestion, frothy sputum, organ failure such as oliguria. Right
Side: Jugular vein distention, ascending dependent edema, abdominal distention, polyuria ar rest, liver enlargement,
2. A nurse is assessing a client who is experiencing renal colic from a calculus in left renal pelvis. Identify the area
where the nurse should expect the client to have referred pain. ( Find “hot spots†in the artwork) Pain travels
downward to the inguinal area and lower back
Renal colic occurs in the kidney area. Referred pain is somewhere that happens in another place other than
where the pain should be felt.
2. A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which
of the following actions should the nurse take? (Select all the apply?). Check answer i read pg 644-647 med surg
it’s not so specific p. 370 ch 57 pdf
a. monitor the access site for drainage.- to check for sxs of infection.
b. Strip the catheter tubing
c. Measure the amount of the dialysate outflow
d. Raise the client to high fowlers position- they must lie supine
e. Position the client to her other side.
3. A nurse is planning to insert an indwelling catheter for a female client. Which of the following actions should the nurse
plan to take? Ati video tutorials foley
a. Collect urine specimen from the drainage bag 1 hr after insertion
b. Raise the head of the bed to 45 degrees prior to insertion
c. Secure the catheter to the client's inner thigh
d. Attach the bag to the rail of the bed. –under non movable area
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