Question 1

1 / 1 pts
A 70-year-old patient with swelling in his ankles is seen in the clinic. When lying supine,
and the head of the bed is elevated greater than 45 degrees, the nurse observes the
external jugular veins are full and distended. The nurse knows this is as a result of

  
decreased fluid volume.
 
  
increased cardiac output
 
  
narrowing of jugular veins
 
  
right-sided heart failure
 
Because no cardiac valve exists to separate the superior vena cava from the right
atrium, the jugular veins give information about activity on the right side of the heart.
They reflect filling pressures and volume changes. Fully distended neck veins with the
client's position elevated more than 45 degrees indicates right-sided heart failure.
Because no cardiac valve exists to separate the superior vena cava from the right
atrium, the jugular veins give information about activity on the right side of the heart.
They reflect filling pressures and volume changes. Fully distended neck veins with the
client's position elevated more than 45 degrees indicates right-sided heart failure.
 
 
Question 2
1 / 1 pts
The nurse is assessing a client with a cardiac condition who complains of fatigue and
nocturia. The nurse should recognize what implication of this statement?
 

  
The client may be at increased risk for myocardial infarction.
 
  
The client may have developed a cardiac conduction problem
 
   
The client may be experiencing symptoms of heart failure.
 
  
The client's cardiac problem is being adequately compensated for
 
With heart failure, increased renal perfusion during periods of rest or recumbency may
cause nocturia. This does not signal CAD, a conduction problem, or adequate
compensation.
 
With heart failure, increased renal perfusion during periods of rest or recumbency may
cause nocturia. This does not signal CAD, a conduction problem, or adequate
compensation.
 
 
IncorrectQuestion 3
0 / 1 pts
During the patient scenario for Charles Jones, what were the priority findings related to
their congestive heart failure?

  
Patient’s history of smoking
 
  
Heart rate regular with atrial fibrillation
 
  
Bilateral nonpitting edema
 
  
Crackles noted to upper and lower lobes anterior, lateral and posterior
 
Patient history of smoking and possible damage over the 20yrs he was smoking
exacerbates the possible damage to his lung tissue. Patient was experiencing 2+ pitting
edema bilaterally. Crackles were noted only at the bases posteriorly. The heart rate was
irregular with atrial fibrillation not regular
 
 
Question 4
1 / 1 pts
A nurse is providing and assessment of a client's lower extremities reveals unilateral
edema of the right foot and ankle. The nurse notes their 2+ unilateral edema. Which of
the following would be priority action for the nurse to do next?
 

  
Check for bilateral varicosities
 
  
Compare measurements of both extremities
 
  
Perform the Allen test
 
  
Palpate the femoral pulses
 
If the legs appear asymmetric, the nurse should measure each leg and then compare
the measurements to confirm the difference. The Allen test is used to evaluate the
patency of the radial or ulnar arteries. Checking for bilateral varicosities is not indicated,
as the client's assessment findings are unilateral edema. Assessment of femoral pulses
is unrelated to edema; if a concern for circulation arises, assess the more distal pulses.
 
If the legs appear asymmetric, the nurse should measure each leg and then compare
the measurements to confirm the difference. The Allen test is used to evaluate the
patency of the radial or ulnar arteries. Checking for bilateral varicosities is not indicated,
as the client's assessment findings are unilateral edema. Assessment of femoral pulses
is unrelated to edema; if a concern for circulation arises, assess the more distal pulses.
 
 
Question 5
1 / 1 pts
A nurse is assessing a client for possible fluid overload. Which assessment finding is
most consistent with this diagnosis?
 

  
Moist, plump tongue
 
   
Crackles during auscultation
 
  
Venous filling of 3 seconds
 
  
Boggy eyeball
 
Crackles noted during suggest fluid retention. Venous filling of 3 seconds and a moist,
plump tongue are normal findings. A boggy eyeball suggests loss of third-space fluid
and consequent dehydration.
Crackles noted during auscultation suggest fluid retention. Venous filling of 3 seconds
and a moist, plump tongue are normal findings. A boggy eyeball suggests loss of third-
space fluid and consequent dehydration.