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
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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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering an antipyretic is not the next action that the nurse should initiate because it does not address the priority problem of potential brain damage or death caused by meningococcal meningitis, which is a bacterial infection of the meninges that can rapidly progress to septic shock or disseminated intravascular coagulation.
Choice B reason: Decreasing environmental stimuli is not the next action that the nurse should initiate because it does not address the priority problem of potential brain damage or death caused by meningococcal meningitis, which can impair the function of the central nervous system and cause increased intracranial pressure, seizures, coma, or cranial nerve palsies.
Choice C reason: Assessing the cranial nerves is the next action that the nurse should initiate because it can provide vital information about the extent and severity of brain involvement caused by meningococcal meningitis, which can affect any or all of the 12 pairs of cranial nerves that control sensory and motor functions of the head and neck.
Choice D reason: Completing a vascular assessment is not the next action that the nurse should initiate because it does not address the priority problem of potential brain damage or death caused by meningococcal meningitis, which can cause inflammation and damage of blood vessels in various parts of the body, leading to ischemia, necrosis, or gangrenE.
Correct Answer is D
Explanation
Choice A reason: The client's financial resources are not the most important factor for the nurse to consider because Meals-on-Wheels is a program that provides low-cost or free meals to seniors and people with disabilities who are unable to cook or shop for themselves.
Choice B reason: The client's level of family support is not the most important factor for the nurse to consider because Meals-on-Wheels is a program that aims to reduce social isolation and improve nutrition for homebound clients, regardless of their family situation.
Choice C reason: The client's access to transportation is not the most important factor for the nurse to consider because Meals-on-Wheels is a program that delivers meals directly to the client's home, eliminating the need for transportation.
Choice D reason: The client's ability to prepare meals is the most important factor for the nurse to consider because Meals-on-Wheels is a program that caters to clients who have difficulty or inability to cook or shop for themselves due to physical, mental, or environmental limitations.
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