Author Question: The nurse is performing an initial assessment on a new patient with suspected right-sided heart ... (Read 96 times)

go.lag · **on:** Jun 25, 2018

The nurse is performing an initial assessment on a new patient with suspected right-sided heart failure. Which finding(s) is/are consistent with the patient's potential diagnosis? (Select all that apply.)

a. Clammy skin
b. Splenomegaly
c. Abdominal distention
d. Wheezing
e. Dyspnea

Question 2

A patient comes to the ambulatory care clinic after getting hay into the eyes while farming. Which action(s) should the nurse implement? (select all that apply.)

a. Flush the eye with warm saline.
b. Hold the eyelids open.
c. Tilt the head back.
d. Use a moistened sterile cotton swab.
e. Ask the patient to rub the eyes with the lids closed to produce more tears.

jamesnevil303 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

B, C, E
Signs and symptoms of right-sided CHF include fatigue, peripheral edema, gastrointestinal con-gestion and abdominal distention, ascites with liver congestion, splenomegaly, and dyspnea. Clammy skin and wheezing are symptoms of left-sided CHF.

Answer to Question 2

A, B, C, D
If the foreign body is not deeply embedded in the tissues of the eye, it can easily be removed by irrigation. Irrigation with clear, lukewarm water or sterile water or saline is used to remove a for-eign body sticking to the cornea. Have the patient tilt the head back. Hold the eyelids open to prevent blinking. Sometimes a speck of foreign matter on the cornea can be removed with a moistened, sterile cotton swab. The goals of treatment will be to remove the foreign objects from the eyes and to prevent further injury to the eye. Rubbing an irritated eye may cause a corneal abrasion.