A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Choice A rationale Dyspnea, or shortness of breath, is primarily a clinical manifestation of left-sided heart failure rather than right-sided failure. In left-sided failure, the heart cannot effectively pump blood into the systemic circulation, causing blood to back up into the pulmonary veins and capillaries. This increased pulmonary hydrostatic pressure leads to fluid leaking into the alveoli, resulting in respiratory distress. While severe right-sided failure can eventually affect the lungs, it is not the hallmark initial finding. Choice B rationale Frothy, pink-tinged sputum is a classic sign of pulmonary edema, which is a life-threatening complication of acute left-sided heart failure. This occurs when the left ventricle fails so significantly that fluid is forced into the air sacs of the lungs. The pink color comes from the rupture of small capillaries in the lungs. In contrast, right-sided heart failure involves systemic venous congestion, which does not typically produce fluid accumulation within the lung's alveolar spaces. Choice C rationale Peripheral edema is a hallmark finding of right-sided heart failure because the right ventricle is unable to pump blood effectively into the pulmonary artery. This leads to a backup of blood in the right atrium and the systemic venous system. The resulting increase in venous hydrostatic pressure forces fluid out of the capillaries and into the interstitial tissues, most commonly in the feet, ankles, and legs. Other signs include jugular venous distention and hepatomegaly due to systemic congestion. Choice D rationale Orthopnea is the sensation of breathlessness that occurs when a person lies flat, often requiring them to use multiple pillows to sleep. This symptom is caused by the redistribution of fluid from the lower extremities to the lungs when reclining, which increases pulmonary congestion. Like dyspnea and frothy sputum, orthopnea is a definitive sign of left-sided heart failure, reflecting the heart's inability to handle the venous return from the lungs when the body is in a horizontal position.