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:
Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.
Choice B rationale:
This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.
Choice C rationale:
Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.
Choice D rationale:
Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.
Correct Answer is C
Explanation
Choice A rationale:
Addiction involves a dependence on a substance or behavior that leads to withdrawal symptoms when the substance or behavior is discontinued. The client's handwashing behavior is not related to addiction.
Choice B rationale:
Phobia refers to an irrational and intense fear of a specific object or situation. While the client's avoidance of sitting on chairs in the day area may be related to anxiety, it does not represent a specific phobia.
Choice C rationale:
Compulsion is the correct answer because the client's handwashing ritual is an example of compulsive behavior. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rigid rules. In this case, the client is compelled to engage in the ritual to alleviate anxiety or distress.
Choice D rationale:
Obsession refers to persistent and intrusive thoughts, urges, or images that cause distress and anxiety. While the client's handwashing ritual may be related to obsessive thoughts about cleanliness, the primary clinical behavior being exhibited is the compulsive handwashing itself.
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