The practical nurse (PN) is assisting with the admission of a client with complications of left- sided heart failure. Which focused assessment should the PN implement first?
Heart sounds
Mood and affect
Chest pain
Bilateral lung sounds
The Correct Answer is D
The correct answer is choice D - Bilateral lung sounds.
Choice A rationale:
Heart sounds. While assessing heart sounds is crucial, the question specifically mentions complications of left-sided heart failure, which primarily affects the lungs. Therefore, assessing lung sounds is a higher priority in this situation.
Choice B rationale:
Mood and affect. While assessing the client's mood and affect is important for holistic care, it is not the most critical assessment to implement first in the case of left-sided heart failure complications.
Choice C rationale:
Chest pain. Although chest pain may be a symptom of left-sided heart failure complications, assessing bilateral lung sounds takes precedence as it directly relates to the client's respiratory status.
Choice D rationale:
Bilateral lung sounds. In left-sided heart failure, fluid can accumulate in the lungs, leading to pulmonary congestion and impaired gas exchange. Therefore, assessing lung sounds helps identify any respiratory distress early on, allowing prompt intervention and prevention of further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
Correct Answer is B
Explanation
This is the best intervention for the PN to implement because it relieves the muscle spasm and reduces the pain of a leg cramp. Leg cramps are common during pregnancy and labor due to changes in calcium levels, fluid balance, or pressure on nerves and blood vessels.
A. Massaging the calf and foot is not recommended because it may increase pain or cause injury to the muscle or nerve.
C. Checking the pedal pulse in the affected leg is not necessary unless there is a suspicion of vascular compromise or thrombosis, which are unlikely causes of a leg cramp.
D. Elevating the leg above the heart is not helpful because it may impair blood flow or increase pressure on the nerve or muscle.
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