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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Reviewing the blood pressure measurement is not the primary concern here; the issue is that the UAP is using the incorrect arm for the measurement.
B. The blood pressure should be measured on the non-operative side. Measuring on the operative side can cause discomfort, potential injury, or interfere with the healing process.
C. Elevating the arm after recording the blood pressure is not a standard requirement post-mastectomy. The immediate concern is the proper measurement site for the blood pressure.
D. A manual blood pressure cuff is not required for accuracy in this situation; the key issue is to use the non-operative arm for measurement.

A. Assess the degree of skin elasticity. B. Record palpated skin temperature. C. Measure the depth of indentation. D. Observe for swelling and inflammation.

Correct Answer is A

Explanation

A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.

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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?

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Correct Answer is B

Explanation

In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

Correct Answer is A

Explanation

The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?

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