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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Related Questions
Correct Answer is A
Explanation
The prescription for Ampicillin 500 mg PO q8h means that the client should take 500 mg of Ampicillin orally every 8 hours. "PO" stands for "by mouth," indicating that the medication should be taken orally. The medication is prescribed at 1000, and the next dose is due at 1300 (1:00 PM).
The other options are as follows:
B. Lisinopril 5 mg PO every day: This medication is prescribed to be taken once a day, not every 8 hours. It is not due at 1300.
C. Metformin 1000 mg PO BID: This medication is prescribed to be taken twice a day (BID), but it is not due at 1300. The timing for the next dose depends on when the first dose was administered.
D. Pantoprazole 40 mg PO every day: This medication is also prescribed to be taken once a day, not every 8 hours. It is not due at 1300.
Correct Answer is C
Explanation
This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic effect. However, this also means that the client is at a higher risk of developing toxicity or side effects from the medication.
The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inflammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.
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