60. What signs will a nurse observe in a client who is experiencing right-sided heart failure? Select all that apply.
60. What signs will a nurse observe in a client who is experiencing right-sided heart failure? Select all that apply.
. Bilateral ankle edema.
. Jugular venous distention (JVD).
. Crackles on auscultation.
. Enlarged liver.
. Sacral edema.
Test-Taking Tip
Visualize: if the right side of the heart cannot pump the blood, where would the effects of the backpressure be noted?
Content Area: Adult Health, Cardiology; Integrated Process: Nursing Process, Assessment; Cognitive Level: Comprehension; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is correct because the heart is unable to handle the venous return, and it will back up into the venous system, causing the ankle edema. Answer 2 is correct because the heart is unable to adequately pump the blood through the right side of the heart, so there is a back-pressure and JVD. Answer 3 is incorrect because crackles would indicate left-sided heart failure. Answer 4 is correct because organ enlargement will occur from the back-pressure with the failing heart. Answer 5 is correct because the right side of the heart cannot handle the venous return, and the pressure will cause systemic edema.