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 B
Explanation
Choice A rationale:
CP being one of the most common permanent physical disabilities in children is a general statement but does not directly address the mother's question about the progression of her child's impaired movements. It does not provide an explanation for the potential course of CP.
Choice B rationale:
Brain damage with CP is not progressive but does have a variable course. This response provides the best explanation to the mother's question. CP is a static neurological condition, which means that the initial brain injury that led to CP does not worsen over time. However, the functional abilities and impairments of a child with CP can vary widely and may change as the child grows and develops. Some children may improve with therapy and interventions, while others may have relatively stable impairments.
Choice C rationale:
Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.
Choice D rationale:
Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro
Correct Answer is B
Explanation
Choice A rationale:
Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.
Choice B rationale:
Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.
Choice C rationale:
Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.
Choice D rationale:
Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.
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