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 A
Explanation
Choice A rationale:
The combination of trimethoprim and sulfamethoxazole has a synergistic effect, which means that the two drugs work together to inhibit bacterial growth more effectively than either drug alone. This combination is commonly used to treat urinary tract infections (UTIs) caused by susceptible bacteria.
Choice B rationale:
The combination of trimethoprim and sulfamethoxazole does not have an additive effect that reduces the dosage and frequency of administration of each drug. Instead, it is prescribed as a fixed combination with specific dosages of each drug.
Choice C rationale:
The combination of trimethoprim and sulfamethoxazole does not have an antagonistic effect that prevents the development of resistance to either drug. In fact, the combination is chosen because it covers a broader spectrum of bacteria and reduces the likelihood of resistance development.
Choice D rationale:
The combination of trimethoprim and sulfamethoxazole does not have a selective effect that targets only the bacteria causing the UTI and spares the normal flora. It affects a wide range of bacteria, including both pathogenic and normal flora.
Correct Answer is B
Explanation
Choice A rationale:
4012 mg/day is not the correct answer. To calculate the maximum safe dosage of valproic acid, you need to convert the client's weight from pounds to kilograms. The client's weight in kilograms can be calculated by dividing the weight in pounds by 2.2. Therefore, 176 pounds divided by 2.2 equals 80 kilograms. The maximum safe dosage is 60 mg/kg/day, so 60 mg multiplied by 80 kg equals 4800 mg/day.
Choice B rationale:
Step 1: Convert the client’s weight from pounds to kilograms. We know that 1 kg is approximately equal to 2.2 pounds. So, we have:
176 pounds ÷ 2.2 = 80 kg (approximately)
Step 2: Calculate the maximum safe dosage for the client. We know that the maximum safe dosage of valproic acid is 60 mg/kg/day. So, we have:
60 mg/kg/day × 80 kg = 4800 mg/day
So, the maximum safe dosage for a client who weighs 176 pounds is4800 mg/day.
Choice C rationale:
3520 mg/day is not the correct answer. It does not accurately calculate the maximum safe dosage based on the client's weight.
Choice D rationale:
6171 mg/day is not the correct answer. It is significantly higher than the correct calculation and would exceed the maximum safe dosage for the client's weight.
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