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 {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}
Explanation
Coarse breath sounds are typically associated with respiratory distress, indicating fluid or secretions in the airways.
Irritability can be a sign of both cerebral edema and respiratory distress as it may stem from hypoxia or increased intracranial pressure.
Seizure activity is more specifically related to cerebral edema, which can increase intracranial pressure and provoke seizures.
Decreased level of consciousness can occur in both conditions: cerebral edema (due to increased intracranial pressure) and respiratory distress (due to hypoxia).
Bradycardia is more indicative of cerebral edema, especially when associated with increased intracranial pressure and resultant autonomic dysregulation.
Correct Answer is B
Explanation
A. The client's contractions are not regular or intense enough to indicate active labor, so immediate hospital admission is not necessary.
B. Instructing the client to call the clinic when her contractions occur 5 minutes apart for one hour ensures she is monitored for the progression of labor and can seek timely assistance when labor becomes more active.
C. While a urinary tract infection could cause contractions, the primary focus should be on monitoring labor progression, not diagnosing a UTI at this stage.
D. Hydration is important, but the primary instruction should relate to monitoring contraction patterns for signs of active labor.
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