Question

The nurse provides care for the client diagnosed with left-sided heart failure. Which data documented by the nurse support the client's current diagnosis? (Select all that apply.)

A) The client leans over the bedside table and pauses often while speaking.
B) The client has pitting edema on bilateral lower extremities.
C) The client's lung sounds are positive for crackles bilaterally.
D) The client grimaces with palpation of the right upper abdominal quadrant.
E) The client's heart rate as 128 beats/min.
F) The client has distended neck veins.

Answer 1

The nurse documented data supporting the client's diagnosis of left-sided heart failure including bilateral crackles in lung sounds, pitting edema in bilateral lower extremities, and an increased heart rate of 128 beats/min.

Step-by-step explanation:

Left-sided heart failure is characterized by the inadequate pumping of blood from the left side of the heart, resulting in fluid backup in the lungs. The data documented by the nurse that support the client's diagnosis of left-sided heart failure include:

1. The client's lung sounds are positive for crackles bilaterally. Crackles, also known as rales, are abnormal sounds heard during breathing and indicate the presence of fluid or mucus in the lungs.
2. The client has pitting edema on bilateral lower extremities. Pitting edema is a condition where the swollen area retains an imprint when pressure is applied and is often seen in patients with heart failure due to fluid retention.
3. The client's heart rate is 128 beats/min. An increased heart rate can be a compensatory response to decreased cardiac output in heart failure.