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:
Drinking electrolyte fluid replacements may be necessary if the client is dehydrated due to diabetic ketoacidosis (DKA). However, addressing the increased thirst, which is a sign of DKA, should involve insulin administration to correct the underlying problem of high blood sugar.
Choice B rationale:
Giving a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a client with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.
Choice C rationale:
Resuming normal physical activity may not be advisable when a client is experiencing early signs of DKA. Strenuous physical activity can exacerbate hyperglycemia, and the primary focus should be on insulin administration and rehydration.
Choice D rationale:
Measuring urine output over the next 24 hours is important for monitoring hydration status in a client with DKA. However, the immediate priority is to address the increased thirst and hyperglycemia with insulin therapy.
Correct Answer is ["B"]
Explanation
The correct answer is Choice B.
Choice A rationale: While notifying the charge nurse about the client’s condition is important, it is not the most critical action. The charge nurse’s role would be to coordinate care and ensure appropriate resources are available, but the immediate safety and well-being of the client and others in the facility is the priority. Therefore, this choice is not the most important action for the nurse to take.
Choice B rationale: Instituting droplet precautions, placing the client in a private room, and keeping the door closed is the most important action. COVID-19 is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. It can also be spread by touching a surface or object that has the virus on it and then touching the mouth, nose, or eyes. Therefore, it is crucial to implement droplet precautions to prevent the spread of the virus. This includes wearing a mask, eye protection, and a gown and gloves when caring for the client. The client should also be placed in a private room with the door closed to further prevent the spread of the virus.
Choice C rationale: While it is important for the client to inform others that they may have been potentially exposed, this is not the most critical action. The priority is to prevent the spread of the virus within the healthcare facility. Once the client is appropriately isolated and precautions are in place, the client can be educated and assisted with notifying others about potential exposure.
Choice D rationale: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is a standard procedure when collecting specimens for testing. However, this action does not address the immediate need to prevent the spread of the virus within the healthcare facility. Therefore, this choice is not the most important action for the nurse to take.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today