The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?
Inspect for sacral edema.
Measure urinary output.
Auscultate all lung fields.
Check mental acuity.
Check mental acuity.
The Correct Answer is C
When assessing an older client with left-sided heart failure (HF), the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. Left-sided heart failure is characterized by the inability of the left ventricle to effectively pump blood, leading to fluid accumulation in the lungs. Auscultating all lung fields allows the PN to assess for the presence of abnormal lung sounds such as crackles, indicating pulmonary congestion.
In summary, when assessing an older client with left-sided heart failure, the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. This allows for the detection of abnormal lung sounds associated with pulmonary congestion, a hallmark sign of left-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. "I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates an understanding that certain characteristics of seizures, such as prolonged duration or multiple seizures in succession, may require medical attention and evaluation.
C. "I may never know why I started having seizures." This statement acknowledges the possibility that the underlying cause of the seizures may remain unknown. Seizure etiology can vary, and in some cases, the specific cause cannot be determined despite diagnostic tests.
D. "Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement recognizes the potential benefits of wearing a medic alert bracelet, which can provide crucial information about the client's condition in case of emergencies. It emphasizes the client's autonomy in making the decision, showing an understanding of the role and significance of the bracelet.
The following statement does not indicate understanding:
"There are really no lifestyle changes that I can do that will affect my risk of having another seizure." This statement is incorrect, as there are lifestyle modifications that can help reduce the risk of seizures, such as getting enough sleep, managing stress, avoiding triggers (if known), and taking prescribed medications as directed.
Regarding the statement "I can stop taking the phenytoin if I go for a while and don't have a seizure," it is not included in the given options.
Correct Answer is D
Explanation
Tramadol is an opioid analgesic that can depress the respiratory system and potentially cause respiratory depression. Therefore, it is crucial for the PN to closely monitor the client's breathing pattern, depth, and rate. Assessing for signs of shallow or slow breathing is important to detect any potential respiratory depression and take appropriate action promptly.
The other options listed are not directly related to the administration of tramadol:
A. Encouraging the client to resume normal activities after medication administration is not an appropriate intervention for a client experiencing torticollis. The focus should be on pain management, rest, and implementing measures to relieve the torticollis.
B. Observing the client for involuntary movements of the lips and tongue every day is not specifically related to tramadol. This intervention is more relevant to monitoring for tardive dyskinesia, a side effect associated with certain antipsychotic medications.
C. Performing a daily whisper test of the client's hearing to detect symptoms of ototoxicity is not necessary with tramadol. Ototoxicity refers to damage to the inner ear, often caused by specific medications, but tramadol is not known to cause ototoxic effects.
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