NCLEX-RN
NCLEX RN Cardiovascular Questions Questions
Extract:
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
Question 1 of 5
Click to indicate whether each clinical finding is seen in left-sided heart failure, right-sided heart failure, or both.
| Clinical Finding | Left-sided Heart Failure | Right-sided Heart Failure | Or Both |
|---|---|---|---|
| Crackles auscultated bilaterally | |||
| Bilateral lower extremity edema | |||
| Paroxysmal nocturnal dyspnea | |||
| Fatigue | |||
| Weight gain of 4 pounds | |||
| Accessory muscle use | |||
| Jugular vein distension |
Correct Answer: A,B,C,D,E,F,G
Rationale: A: Left-sided - Crackles result from pulmonary edema in left heart failure. B: Right-sided - Edema is due to systemic venous congestion in right heart failure. C: Left-sided - Paroxysmal nocturnal dyspnea is caused by pulmonary congestion. D: Both - Fatigue occurs in both due to reduced cardiac output. E: Right-sided - Weight gain reflects fluid retention from right heart failure. F: Left-sided - Accessory muscle use indicates respiratory distress from pulmonary edema. G: Right-sided - Jugular vein distension is due to right heart failure.
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Question 2 of 5
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