Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
4. Which clinical feature found on assessment should indicate to a nurse that a client has congestive heart failure?
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
4. Which clinical feature found on assessment should indicate to a nurse that a client has congestive heart failure?
. Fatigue and dyspnea.
. Cheyne-Stokes breathing and orthostatic hypotension.
. Liver tenderness and peripheral edema.
. Pulmonary crackles and weak pulses.
Test-Taking Tip
Review the clinical differences between right-sided versus left-sided heart failure.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
.
Answer 1 is correct because congestive heart failure (CHF) or right-sided heart failure reduces cardiac output; and circulating O2 is reduced, producing fatigue and shortness of breath. Answer 2 is incorrect because Cheyne-Stokes breathing occurs from neurologic problems or problems with respiratory gas exchange. Answer 3 is incorrect because the liver may be enlarged but not painful. Answer 4 is incorrect because crackles would be more consistent with left-sided failure, not CHF (right-sided failure).