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

Chest pain

Bilateral lung sounds

Mood and aﬀect

Answer and Explanation

The Correct Answer is C

c) Bilateral lung sounds.

Explanation:

When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of ﬂuid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and ﬂuid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.

While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and aﬀect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admited with complications of left-sided heart failure.

The other options are considered incorrect because they are not the priority assessments when admitting a client with complications of left-sided heart failure.

Option a) Heart sounds: While assessing heart sounds is important in evaluating cardiac function, the priority in this scenario is to assess for pulmonary congestion and impaired gas exchange. Assessing bilateral lung sounds allows the practical nurse to gather immediate information about the client's respiratory status and the presence of ﬂuid in the lungs.

Option b) Chest pain: Chest pain is a significant symptom that should be assessed promptly, as it could indicate various cardiac or respiratory conditions. However, in this specific scenario, the priority is to assess for signs of pulmonary congestion, which can have a more immediate impact on the client's respiratory function.

Option d) Mood and aﬀect: Assessing the client's mood and aﬀect is important for a comprehensive assessment of their emotional well-being. However, when admitting a client with complications of left- sided heart failure, the priority is to assess their physical condition, particularly the respiratory status, to address any immediate concerns related to pulmonary congestion and impaired gas exchange.

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Correct Answer is C

Explanation

Choice A reason: Mitigation is not the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is the level that focuses on reducing or eliminating risks and vulnerabilities before a disaster occurs, such as building levees or dams, enforcing zoning codes, or implementing insurance policies.

Choice B reason: Security is not the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is not a level of the framework, but rather a cross-cutting function that supports all levels by ensuring the protection of people, property, and information from threats or hazards.

Choice C reason: Preparedness is the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is the level that focuses on enhancing the readiness and capabilities of individuals, organizations, and communities to respond to and recover from a disaster, such as developing plans, conducting trainings, or providing education.

Choice D reason: Response phase is not the level of the National Response Framework that involves educating the residents about evacuation routes and emergency shelters because it is the level that focuses on delivering immediate assistance and resources to save lives, protect property, and meet basic needs during and after a disaster, such as activating emergency operations centers, deploying teams, or providing shelter.

A. Turn the infant onto the right side. B. Suction the oral and nasal passages. C. Give oxygen by positive pressure. D. Stimulate the infant to cry.

Correct Answer is B

Explanation

In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.

Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airﬂow and prevent further respiratory distress in the infant.

Let's brieﬂy evaluate the other options:

a) Turn the infant onto the right side.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

c) Give oxygen by positive pressure.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

d) Stimulate the infant to cry.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway take precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airﬂow and ensure adequate ventilation for the infant.

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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?

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Correct Answer is C

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A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

Correct Answer is B

Explanation

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