The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?
Measure urinary output.
Auscultate all lung fields.
Check mental acuity.
Inspect for sacral edema.
The Correct Answer is B
A. Measure urinary output.
Measuring urinary output is important for monitoring fluid balance but is not the most critical intervention for assessing left-sided heart failure specifically.
B. Auscultate all lung fields.
Auscultating lung fields is crucial for assessing signs of pulmonary edema, a key symptom of left-sided heart failure. It provides direct information about the severity of the condition and guides further management.
C. Check mental acuity.
Checking mental acuity can be useful but is not the most critical intervention for managing left-sided heart failure. It is less directly related to evaluating the severity of heart failure compared to lung auscultation.
D. Inspect for sacral edema.
Inspecting for sacral edema is more relevant for right-sided heart failure. For left-sided heart failure, the priority is evaluating pulmonary symptoms, not peripheral edema.
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Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Client positioning during the procedure should be documented to ensure that the procedure was performed correctly and that the client was appropriately positioned for catheter insertion.
B. The amount of lubricant used is not a standard detail for documenting catheter insertion. Documentation focuses on the procedure's outcomes and specific technical details rather than quantities of materials used.
C. The size of the urinary catheter should be documented as it is a critical detail for future reference and to ensure that the catheter was appropriate for the client’s needs.
D. The appearance of the urine obtained should be documented as it provides important information about the client’s urinary status and can indicate potential issues like infection or hematuria.
E. While the amount of urine obtained might be relevant for assessing urinary retention, it is not a standard part of the initial documentation for catheter insertion unless there was a significant volume change or specific concern.
Correct Answer is B
Explanation
A. A warm sleeping environment may exacerbate pruritus by increasing skin dryness and irritation. Cool, comfortable environments are generally better for clients with pruritus.
B. Keeping fingernails trimmed short helps prevent skin damage and infection caused by scratching. This is a practical and effective measure to manage pruritus.
C. Discouraging the use of skin lubricants is not advisable as they can help soothe and moisturize dry, itchy skin. Emollients and moisturizers are often recommended to manage pruritus.
D. Advising against any type of tub bath is not necessary. Instead, the use of lukewarm baths with added colloidal oatmeal or other soothing agents can help reduce pruritus.
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