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.
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.
Let's evaluate the other options:
a) Inspect for sacral edema.
Sacral edema is commonly associated with right-sided heart failure, not left-sided heart failure. While it is important to assess for edema in clients with heart failure, inspecting for sacral edema may not be the most immediate and crucial intervention in this specific case.
b) Measure urinary output.
Measuring urinary output is a valuable assessment in many clinical situations, but it may not be the most vital intervention in the context of left-sided heart failure. Monitoring urinary output is more relevant in assessing kidney function and fluid balance rather than directly assessing the severity of left-sided heart failure.
d) Check mental acuity.
Checking mental acuity is important in assessing the overall condition of the client, but it is not the most crucial intervention specifically related to left-sided heart failure. Mental status evaluation is more useful in identifying signs of altered mental status or potential complications, rather than directly assessing the impact of left-sided heart failure.
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 D
Explanation
Choice A rationale:
Washing the patient's left side first and then moving to the right side does not demonstrate an individualized approach or consideration for the patient's preferences and abilities. It is important to involve the patient in the decision-making process, especially when they have hemiparesis, to promote their autonomy and comfort.
Choice B rationale:
Washing the patient's right side first and then moving to the left side does not consider the patient's preference and may not align with their abilities or comfort. It is essential to prioritize the patient's preferences and needs.
Choice C rationale:
Washing both sides of the patient at the same time, starting from the head and moving down, may not be feasible or comfortable for the patient, especially if they have hemiparesis. This approach does not demonstrate an individualized care plan based on the patient's specific condition.
Choice D rationale:
Asking the patient which side they prefer to wash first and then following their preference is the most patient-centered and appropriate approach. This approach respects the patient's autonomy and ensures that their needs and comfort are prioritized during the bathing process. It allows for individualized care based on the patient's abilities and preferences.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
An elevated serum creatinine level can indicate kidney dysfunction or damage, which can be a possible adverse effect of amoxicillin-clavulanate. The kidneys are responsible for excreting the medication, and elevated creatinine levels suggest impaired renal function.
Choice B rationale:
An elevated serum alanine aminotransferase (ALT) level is indicative of liver dysfunction or damage. Amoxicillin-clavulanate can sometimes cause hepatotoxicity as a side effect, and elevated ALT levels may suggest this adverse effect.
Choice D rationale:
An elevated white blood cell count (leukocytosis) can be a possible adverse effect of amoxicillin-clavulanate, indicating an increase in the body's immune response. This could be due to an allergic reaction or other adverse reactions to the medication.
Choice C rationale:
An elevated serum potassium level is not typically associated with amoxicillin-clavulanate use. This finding is more likely related to other factors such as kidney dysfunction or certain medications like potassium-sparing diuretics.
Choice E rationale:
An elevated platelet count is not typically associated with amoxicillin-clavulanate use. This finding is more likely related to other factors, such as a bone marrow disorder or inflammation.
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