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 B
Explanation
Ask the client to describe what happened.
Calling the agency-based client advocate (Choice A) should not be the first action taken in this situation. While involving an advocate might be necessary at some point, it is more appropriate to address the client's concerns and gather information about the incident first.
Completing a client adverse incident report (Choice C) is an important step to document theevent and any potential issues, but it should not be the first action taken. Before completing the report, the nurse needs to understand the situation from the client's perspective.
Informing the charge nurse of the situation (Choice D) is a reasonable step, but it should not be the first action. It may be necessary to escalate the issue, but understanding the situation from the client's viewpoint should be prioritized.
Correct Answer is D
Explanation
A high blood urea nitrogen (BUN) level indicates impaired renal function, which can be caused by dehydration, infection, or nephrotoxic drugs. Chemotherapy can damage the kidneys and increase the risk of renal failure. The PN should report this finding to the charge nurse, as it may require fluid replacement, dose adjustment, or discontinuation of the chemotherapy.
The other options are not correct because:
A. Periodic nausea and vomiting are common side effects of chemotherapy that can be managed with antiemetics, hydration, and dietary modifications. They are not as urgent as a high BUN level.
B. Decreased deep tendon reflexes may indicate hypocalcemia, hypomagnesemia, or peripheral neuropathy, which can be caused by chemotherapy or other factors. They are not as urgent as a high BUN level.
C. A platelet count of 135,000/mm3 or 135 x 10^9/L is slightly below the normal range, but not significantly low. Chemotherapy can cause thrombocytopenia, which increases the risk of bleeding. The PN should monitor the client for signs of bleeding, but this finding is not as urgent as a high BUN level.
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