Author Question: The nurse is assessing a client being treated for congestive heart failure (CHF). Which physical ... (Read 88 times)

deesands · **on:** Jun 25, 2018

The nurse is assessing a client being treated for congestive heart failure (CHF). Which physical findings would indicate that the client's condition is not improving?

Select all that apply.
A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96
C) Temperature of 98.6 F (37 C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus

Question 2

The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position is most appropriate for this client?

A) Seated in a recliner with 2-3 pillows under feet
B) Lying on the left side with the head of the bed elevated 30
C) Seated in a recliner with 2-3 pillows under head
D) Lying on either side with the head of the bed elevated 30

missalyssa26 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A, D

Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6 F, moderate clear mucus, and a pulse oximetry reading of 96 are all normal findings.

Answer to Question 2

Answer: A

The client with left-sided cardiac failure could develop orthopnea. This is a result of the pulmonary congestion and decreased cardiac output. Being in an upright position will ease the work of breathing. Side-lying positions will not help alleviate or prevent the development of orthopnea. Propping the lower legs up while in a sitting position can help decrease dependent edema, but 2-3 pillows are not needed for sleep.