The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

c) Bilateral lung sounds.

Explanation:

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 admited with complications of left-sided heart failure.

The other options are considered incorrect because they are not the priority assessments when admitting a client with complications of left-sided heart failure.

Option a) Heart sounds: While assessing heart sounds is important in evaluating cardiac function, the priority in this scenario is to assess for pulmonary congestion and impaired gas exchange. Assessing bilateral lung sounds allows the practical nurse to gather immediate information about the client's respiratory status and the presence of fluid in the lungs.

Option b) Chest pain: Chest pain is a significant symptom that should be assessed promptly, as it could indicate various cardiac or respiratory conditions. However, in this specific scenario, the priority is to assess for signs of pulmonary congestion, which can have a more immediate impact on the client's respiratory function.

Option d) Mood and affect: Assessing the client's mood and affect is important for a comprehensive assessment of their emotional well-being. However, when admitting a client with complications of left- sided heart failure, the priority is to assess their physical condition, particularly the respiratory status, to address any immediate concerns related to pulmonary congestion and impaired gas exchange.

Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse because it can expose more people to the chemical spill and worsen their condition. The triage nurse should stop the triage process and alert the emergency department staff about the potential contamination.

Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse because it can prevent further exposure and harm to other clients, staff, and visitors. The emergency department should be cleared and sealed until it is safe to re-enter.

Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse because it can contaminate the room and its equipment, as well as pose a risk to anyone who enters or leaves the room. The client should be isolated in a designated area for decontamination.

Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse because it can delay the treatment and increase the absorption of the chemical into the body. The client should be treated as soon as possible after decontamination.

Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse because it can remove or neutralize the chemical from their skin, clothing, and equipment, as well as reduce their symptoms and complications. The client and EMS crew should be directed to a designated area for decontamination.