ATI RN ADULT MEDICAL SURGICAL PROCTOREDEXAM 2019

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? Dependent edema The nurse should identify that dependent edema is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system. Jugular distention The nurse should identify that jugular vein distention is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system. Weight gain The nurse should identify that weight gain is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system. MY ANSWER The nurse should identify that frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure. Treatment includes fluid restriction and diuretics to decrease preload and reduce pulmonary congestion. Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening. Therefore, the nurse should notify the provider immediately. • RN VATI Adult Medical Surgical 2019