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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Dry mucous membranes and a dry mouth are common side effects of anticholinergic drugs like dicyclomine. These medications block the action of acetylcholine, a neurotransmitter responsible for stimulating secretions in the body. As a result, the client may experience dryness in various parts of the body, including the mouth.
Providing oral care, such as offering the client sips of water or providing a moistening agent for the mouth, can help alleviate the discomfort caused by dryness and promote oral hygiene. It is an appropriate and immediate intervention for the client's current symptoms.
Incorrect:
A. Checking vital signs may not directly address the client's dry mouth, but it is a good practice to assess the client's overall condition.
B. Monitoring hemoglobin would not be necessary in this situation, as it does not directly relate to the client's dry mucous membranes.
C. Notifying the charge nurse may be appropriate if the client's symptoms worsen or if there are other concerning factors, but the priority action in this case is to provide oral care to address the client's discomfort.
Correct Answer is A
Explanation
A. Checking the medical record for the correct signed consent form prior to the examination is the primary responsibility of the practical nurse (PN). Ensuring that the consent form is properly signed and documented in the medical record is crucial for legal and ethical reasons before proceeding with any invasive procedure.
B. While explaining the examination is important, obtaining informed consent is the responsibility of the provider, not the PN. The PN can clarify information but should not be the one to explain the procedure in detail and obtain the signature.
C. Explaining the procedure to a family member and obtaining their signature is not appropriate, as consent must come from the client unless they are incapacitated. Family members cannot give consent for procedures unless legally designated as such.
D. While asking if the client understands the exam and the need for the consent form is a good practice for ensuring informed consent, the PN's responsibility focuses more on verifying that the consent has been properly obtained and documented.
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