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

An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution³.
The temperature of the enema solution aﬀects the eﬀectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work⁴.
The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions³⁴.

Option A is incorrect because the client’s comfort level may not reﬂect the optimal temperature for the

enema.

Option B is incorrect because the temperature of the enema does aﬀect its eﬀectiveness and safety. Option D is incorrect because the temperature is too high and can cause harm to the client.

A. Transport a urine culture sample to the laboratory B. Obtain a post-voided residual (PVR) volume C. Teach the client with ﬂuid restrictions how to measure urine output D. Irrigate an indwelling urinary catheter for a client with bladder suspension E. Empty bedside drainage unit for a client with indwelling urinary catheter

Correct Answer is ["A","E"]

Explanation

The correct answers are:

a) Transport a urine culture sample to the laboratory. Correct

This is a client care intervention that the PN can assign to the UAP. Transporting a urine culture sample to the laboratory is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for handling and labeling the specimen.

b) Obtain a post-voided residual (PVR) volume.

This is not a client care intervention that the PN can assign to the UAP. Obtaining a post-voided residual (PVR) volume is a procedure that requires clinical judgment and skill, as it involves using a bladder scanner or catheterizing the client to measure the amount of urine left in the bladder after voiding.

The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

c) Teach the client with ﬂuid restrictions how to measure urine output.

This is not a client care intervention that the PN can assign to the UAP. Teaching the client with ﬂuid restrictions how to measure urine output is an educational activity that requires clinical judgment and skill, as it involves assessing the client's learning needs, providing clear and accurate instructions, and evaluating the client's understanding and compliance. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

d) Irrigate an indwelling urinary catheter for a client with bladder suspension.

This is not a client care intervention that the PN can assign to the UAP. Irrigating an indwelling urinary catheter for a client with bladder suspension is a procedure that requires clinical judgment and skill, as it involves inserting sterile ﬂuid into the bladder through the catheter to ﬂush out any clots, debris, or bacteria. The UAP is not trained or authorized to perform this task, and it should be done by the PN or another licensed nurse.

e) Empty bedside drainage unit for a client with indwelling urinary catheter. Correct

This is a client care intervention that the PN can assign to the UAP. Emptying bedside drainage unit for a client with indwelling urinary catheter is a routine and non-invasive task that does not require clinical judgment or skill. The UAP should follow the standard precautions and protocols for emptying, measuring, and recording the urine output.

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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

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