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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Changing gloves is important for infection control, but in this context, the main issue is with the technique being used for the client's feet.
B. Soaking the feet is not recommended for clients with diabetes due to the risk of skin damage and infection; it is better to wash the feet gently and inspect them regularly.
C. Checking the client’s feet is important but should be done before washing or soaking, and the main concern here is not to soak the feet at all.
D. While testing water temperature is crucial for safe bathing, the more pressing issue here is the method of foot care for a diabetic client, which is not to soak the feet
Correct Answer is ["A","E","F"]
Explanation
A. Give ibuprofen 400 mg PO every 6 hours PRN for fever
The client has a fever of 101.5° F (38.6° C), so administering ibuprofen to manage the fever is appropriate.
B. Give 1,000 mL sodium chloride now
This prescription is already ordered and being administered, so it does not need to be requested again.
C. Discontinue the peripheral IV
The client needs IV access for fluid administration and potential medications, so discontinuing the peripheral IV is not appropriate.
D. Insert an indwelling urinary catheter
There is no indication of urinary retention or need for precise fluid measurement, making this intervention unnecessary at this time.
E. Apply cardiac telemetry monitoring
Given the client's elevated heart rate and respiratory rate, cardiac telemetry monitoring would help in continuously assessing the client's cardiac status.
F. Collect blood to test electrolyte levels
Due to the client's symptoms and history of decreased fluid intake, electrolyte imbalance is a concern, and testing electrolyte levels is necessary.
G. Prepare to defibrillate the client
There is no indication of a cardiac emergency that would require defibrillation.
H. Collect blood for a type and screen
There is no indication of the need for a blood transfusion, making this intervention unnecessary.
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