• 4 ounce apple Juice 8 ounces milk
• 4 ounces broth
• 4 ounces tea

A client remains on strict intake and output (1&O) on the first postoperative day and documents the last 8 hours of intake on the I&O bedside record above. How many mL should the practical nurse (PN) document in the client's electronic medical record (EMR)?

(Enter numeric value only.)

When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.

While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admitted with complications of left-sided heart failure.

Choice A reason:

Requesting that the man get up and leave disregards the client's autonomy and right to privacy. It can be seen as intrusive and disrespectful, potentially causing embarrassment and distress to the client. In a long-term care facility, residents have the right to engage in consensual relationships. By asking the man to leave, the nurse would be infringing on the client's personal rights and freedoms. This action could also damage the trust and rapport between the nurse and the client, making future interactions more difficult.

Choice B reason:

Reporting the incident to the family breaches the client's confidentiality and privacy. The client has the right to engage in consensual relationships without family interference unless there are concerns about safety or capacity. Involving the family in such personal matters without the client's consent can lead to unnecessary conflict and distress. It is important for healthcare providers to respect the client's autonomy and confidentiality, ensuring that their personal choices are honored and protected.

Choice C reason:

Exiting the room and quietly closing the door respects the client's privacy and autonomy. It acknowledges their right to intimate relationships and maintains their dignity. This action demonstrates respect for the client's personal space and choices, fostering a supportive and respectful environment. By quietly exiting, the nurse avoids causing embarrassment or discomfort, allowing the client to maintain their dignity and privacy. This approach aligns with ethical principles in healthcare, emphasizing respect for the client's autonomy and personal rights.

Choice D reason:

Asking when the nurse should return interrupts the client's private moment. It can be handled more discreetly by returning later without disturbing them. This action, while less intrusive than asking the man to leave, still fails to fully respect the client's privacy. By asking when to return, the nurse is drawing attention to the situation, which can cause embarrassment and discomfort. A more respectful approach would be to quietly exit and return at a later time, ensuring that the client's privacy is maintained.