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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.
Frothy sputum
MY ANSWE R
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.
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A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the
lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm
, Hg. Which of the following acid-base imbalances should the nurse identify that the client is
experiencing?
Respiratory alkalosis
MY ANSWE R
This pH is alkaline (increased) and the PCO is decreased, representing alveolar hyperventilation
2
and resultant respiratory alkalosis.
Respiratory acidosis
This pH is alkaline (increased) and the PCO is decreased. A decreased pH and an increased
2
PCO indicate respiratory acidosis. 2
Metabolic alkalosis
This HCO 24 mEq/L is within the expected range of 21 to 28 mEq/L and the pH is alkaline
3
-
(increased). An increased pH and HCO indicate metabolic alkalosis.
3
-
Metabolic acidosis
This HCO 24 mEq/L is within the expected range of 21 to 28 mEq/L and the pH is alkaline
3
-
(increased). A decreased pH and HCO indicate metabolic acidosis.
3
-
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A nurse is assessing a client who has Cushing's syndrome. Which of the following findings
should the nurse expect?
Vitiligo
Vitiligo is the loss of pigment from areas of a client's skin, causing irregular, white patches.
Vitiligo is a manifestation of adrenal-gland hypofunction.
Osteoporosis
MY ANSWE R
, Osteoporosis is a common finding with Cushing's syndrome. Bones become thinner as a result of
mineral loss and nitrogen depletion, and the risk for fractures increases.
Myxedema
A client who has hypothyroidism can develop myxedema that causes mucinous cellular edema
around the eyes, across the upper back, and in the hands and feet.
Heat intolerance
A client who has hyperthyroidism can develop heat intolerance, along with an increase in
sweating.
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A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify
which of the following lesion characteristics on the client's skin?
A pearly, waxy nodule
MY ANSWE R
A client who has basal cell carcinoma has a nodular lesion with well-defined borders and a
pearly or waxy appearance, resulting from overexposure to the sun, especially on the face, head,
and neck.
An irregular border on a variegated-colored lesion
A client who has melanoma has a lesion with irregular borders and variegated colors of red,
white, and blue, most often on the upper back or lower legs.
A firm, nodular, crusty, or ulcerated lesion