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.

Answer and Explanation

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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Correct Answer is B

Explanation

To prevent injury in a female client with immune thrombocytopenic purpura (ITP) who is transferred to a long-term care facility for physical rehabilitation, the most important action for the practical nurse to implement is to ensure the client has minimal clutter in the room.

ITP is a condition characterized by a low platelet count, which can result in an increased risk of bleeding and bruising. Clutter in the room can pose a hazard and increase the risk of injury. The client may accidentally bump into objects or trip over items, potentially leading to falls or injuries.

Incorrect:

A- Assessing the client for nerve pain or paralysis is important but may not be directly related to preventing injury in this context. It is essential to address these concerns but not the most important action in preventing injury.

C- Evaluating the client's neurological status after exercising is important for overall assessment and monitoring but does not specifically address the prevention of injury.

D- Monitoring the client's blood cell laboratory values is essential for managing the client's condition but does not directly address preventing injury. It focuses more on the medical management of the client's ITP.

A. Report the incident and the UAP for further action by the nurse manager. B. Tell both of them to lower their voices in consideration of other residents. C. Tell the resident and the UAP that shouting is not permitted. D. Enter the room and tell the UAP to leave the room immediately.

Correct Answer is D

Explanation

When the PN witnesses a situation where a resident is shouting profanities and a staff member (UAP) responds inappropriately, the immediate priority is to ensure the safety and well-being of the resident. It is essential to address the situation promptly and prevent further escalation.
Entering the room and instructing the UAP to leave immediately serves several purposes:

1. Protecting the resident: Removing the UAP from the room ensures that the resident is not subjected to further conflict or distress.
2. Maintaining a calm and therapeutic environment: By addressing the disruptive behavior and removing the staff member involved, the PN can help restore a peaceful environment for the resident and other individuals in the facility.
3. Ensuring professional conduct: Shouting and engaging in unprofessional behavior is not acceptable in a healthcare setting. By immediately intervening and directing the UAP to leave the room, the PN reinforces the importance of maintaining a respectful and professional approach to caregiving.
After addressing the immediate concern, the PN should follow up by reporting the incident and providing a detailed account to the nurse manager or supervisor. This allows for appropriate action to be taken, such as further investigation or disciplinary measures if necessary.
The other options mentioned are not the first actions to be taken in this situation:

A. Reporting the incident and the UAP for further action by the nurse manager: While reporting the incident is important, it is not the immediate action required to address the situation in
real-time.

B. Telling both of them to lower their voices in consideration of other residents: While promoting a calm environment is important, addressing the issue of shouting and unprofessional behavior takes precedence over requesting a volume reduction.

C. Telling the resident and the UAP that shouting is not permitted: While it is essential to communicate the expectations of behavior, the immediate focus should be on removing the staff member from the situation and ensuring the resident's well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Correct Answer is B

Explanation

The practical nurse (PN) hears an older resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?

Correct Answer is D

Explanation

The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.)

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Two weeks after cast application, a client with a fractured right arm returns to the clinic for evaluation. The client seems upset and tells the practical nurse (PN) that the healthcare provider said a callus has formed on the bone. Which action should the PN take?

A client with irritable bowel syndrome (IBS) is receiving dicyclomine, an anticholinergic drug. Prior to administering the next dose, the practical nurse (PN) determines that the client's mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take

A client who has four gold seed implants on a chest wall tumor is on radiation precautions. What basic precautions should the practical nurse (PN) observe when administering direct care to this client?