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: "Repeat dose in 1 hour for unrelieved headachE." This instruction is incorrect because sumatriptan should not be taken more than twice in 24 hours.
Choice B reason: "Chew tablet well before swallowinG." This instruction is unnecessary because sumatriptan tablets are meant to be swallowed whole with water.
Choice C reason: "If you experience chest pain, call your physician immediately." This instruction is important because sumatriptan can cause coronary vasospasm, which can lead to angina or myocardial infarction.
Choice D reason: "Take daily to prevent headaches." This instruction is inappropriate because sumatriptan is used to treat acute migraine attacks, not to prevent them.
Correct Answer is C
Explanation
Choice A reason: A skilled nursing facility is not the best option for this client because it provides long-term care for clients who need 24-hour nursing supervision and assistance with activities of daily living, but not intensive rehabilitation.
Choice B reason: Home care services are not the best option for this client because they provide intermittent care for clients who are able to manage most of their needs at home, but not comprehensive rehabilitation.
Choice C reason: A rehabilitation facility is the best option for this client because it provides short-term care for clients who need intensive physical, occupational, and/or speech therapy to restore or improve their function and independencE.
Choice D reason: A sub-acute care facility is not the best option for this client because it provides intermediate care for clients who need less intensive medical and nursing care than in an acute hospital, but not specialized rehabilitation.
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