A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the client’s condition has not improved?
1. Temperature of 98.6°F (37°C)
2. Moderate amount of clear thin mucus
3. Pulse oximetry reading of 96%
4. Wheezing of breath sounds in all lobes
ANSWER
Correct Answer: 4
Rationale 1: A temperature reading of 98.6°F is a normal finding and not an indication of heart failure.
Rationale 2: A moderate amount of clear mucus is a normal finding and not an indication of heart failure.
Rationale 3: A pulse oximetry reading of 96% is a normal finding and not an indication of heart failure.
Rationale 4: Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic of congestive heart failure.
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