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

Answer and Explanation

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.

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Correct Answer is C

Explanation

This is the first action that the PN should take because the catheter size and balloon volume are inappropriate for the client. A #18 urinary catheter is too large for a female client who weighs 50 kg, and a 30 mL balloon may cause bladder trauma or discomfort. The PN should consult with the charge nurse and obtain a smaller catheter (such as #14 or #16) with a 10 mL balloon.

A. Obtaining a 30 mL syringe and a vial of sterile water is not the first action because it does not address the issue of the catheter size and balloon volume.

B. Asking the client if she has previously been catheterized is not the first action because it does not address the issue of the catheter size and balloon volume.

D. Positioning the client and observing the urinary meatus is not the first action because it does not address the issue of the catheter size and balloon volume.

A. The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias. B. The client is at risk for pulmonary embolism, and lifestyle modifications need to be implemented. C. The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction (MI). D. The lab results indicate risk factors for transient ischemic atack (TIA), and neurological vital signs should be monitored.

Correct Answer is A

Explanation

Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suﬀered a myocardial infarction (MI) or heart attack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.

The other options are not correct because:

B. The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.

C. The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood ﬂow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.

D. The lab results do not indicate risk factors for transient ischemic attack (TIA), which is a temporary interruption of blood ﬂow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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