Ati lpn med surg proctored exam (perfusion)
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Explanation & Rationale
A. Dyspnea: Dyspnea is a hallmark of left-sided heart failure due to pulmonary congestion; it can occur with biventricular failure but is not the most prominent isolated sign of right-sided failure. B. Frothy sputum: Frothy, blood-tinged sputum indicates pulmonary edema, which is most closely associated with left-sided heart failure. C. Nocturia: Nocturia can occur in heart failure because when the client lies down overnight peripheral edema is mobilized and the kidneys increase urine production; it may be present but is not the classic primary finding of right-sided failure. D. Jugular venous distention: JVD reflects elevated systemic venous pressure and is a classic and expected sign of right-sided heart failure.
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