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.

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.

Auscultation

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Correct Answer is B

Explanation

Choice A rationale:

Altered consciousness within the first 24 hours after injury is not indicative of a developing epidural hematoma. An epidural hematoma typically manifests as a lucid interval followed by a rapid deterioration in consciousness hours after the injury.

Choice B rationale:

Cushing reflex (increased blood pressure, bradycardia, and irregular respirations) and cerebral edema after 24 hours are characteristic signs of a developing epidural hematoma. This occurs due to the accumulation of blood between the dura mater and the skull, leading to increased intracranial pressure.

Choice C rationale:

Headache and pupillary changes 48 hours after head injury are not specific signs of an epidural hematoma. These symptoms may indicate various other neurological conditions or complications.

Choice D rationale:

Fever, nuchal rigidity, and opisthotonos within hours are suggestive of meningitis rather than an epidural hematoma. These symptoms are not typical of epidural hematomas, which primarily involve alterations in consciousness and increased intracranial pressure.

A. Metabolic alkalosis. B. Respiratory alkalosis. C. Metabolic acidosis. D. Respiratory acidosis.

Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale: Metabolic alkalosis is caused by a loss of acid or a gain of base. It is not typically associated with anxiety or hyperventilation.

Choice B rationale: Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide levels in the blood. This can occur in response to anxiety, pain, or other stressors.

Choice C rationale: Metabolic acidosis is caused by a buildup of acid in the blood or a loss of bicarbonate. It is not typically associated with anxiety or hyperventilation.

Choice D rationale: Respiratory acidosis is caused by hypoventilation, which leads to an increase in carbon dioxide levels in the blood. It is not typically associated with anxiety or hyperventilation.

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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

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