Medical Surgical Assessment & Lung sounds #1

Question

The nurse is assessing a client with left-sided heart failure who is suspected of progressing into pulmonary edema. Which finding will the nurse report to the health care provider that is a manifestation of pulmonary edema?

Answers

  1. Bilateral crackles.
    • Rationale:

      This answer is correct because bilateral crackles may be heard with pulmonary edema as a complication of left-sided heart failure. Fluid accumulates in the pulmonary vascular bed, and crackles may be auscultated.

  2. Peripheral 4+ edema.
    • Rationale:

      This answer is not correct because peripheral edema does not indicate fluid accumulation within the lungs. Also peripheral edema is associated with right-sided heart failure as opposed to left-sided heart failure.

  3. Increased temperature.
    • Rationale:

      This answer is not correct because fever is not associated with pulmonary edema. Fever is an indicator of inflammation/infection.

  4. Respiratory rate of 26 breaths/minute.
    • Rationale:

      This answer is not correct because a respiratory rate above normal is not alone indicative of pulmonary edema. The nurse would auscultate abnormal breath sounds in a client with pulmonary edema as an indicator of fluid being present in the pulmonary vasculature.

Overview

The focus of this question is determining the clinical manifestation that most likely represents the development of pulmonary edema in a client with left-sided heart failure. When the left side of the heart fails, blood backs up into the pulmonary circuit leading to pulmonary congestion and ultimately pulmonary edema.

Explanation

Learning Outcomes

Congestive heart failure occurs when the heart is unable to pump blood forward in order to maintain adequate cardiac output. Signs and symptoms of congestive heart failure will vary depending upon which side of the heart is affected. When the left side of the heart fails, blood backs up into the pulmonary circuit as it is not being pumped forward into systemic circulation. Pulmonary edema results from the back-up of blood into the pulmonary circuit. Auscultation of bilateral crackles indicates the presence of excess fluid in the pulmonary vasculature.

Test Taking Tip

Remember with heart failure; Left = Lung and Right = Peripheral. With left-sided heart failure, there will be pulmonary related symptoms as blood backs up into the pulmonary circulation.

Video Rationale