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 D
Explanation
Choice A reason: Natural history of disease is not an approach that explains the factors that allow the reproduction and spread of infectious disease, but rather a description of how a disease progresses over time from exposure to outcome in the absence of intervention.
Choice B reason: Health promotion is not an approach that explains the factors that allow the reproduction and spread of infectious disease, but rather a process of enabling people to increase control over and improve their health through education, empowerment, and policy changE.
Choice C reason: Levels of prevention are not an approach that explains the factors that allow the reproduction and spread of infectious disease, but rather a classification of interventions based on their timing and purpose in relation to disease occurrencE.
Choice D reason: Epidemiologic triangle is an approach that explains the factors that allow the reproduction and spread of infectious disease, by identifying and analyzing three elements: agent (the cause of disease), host (the person who gets sick), and environment (the conditions that affect transmission).
Correct Answer is C
Explanation
Choice A reason: Delivering a clean voided urine specimen to the laboratory is not the first task that the AP should complete because it is not urgent or time-sensitivE. The specimen can be stored in a refrigerator or on ice until it is delivereD.
Choice B reason: Feeding a client who has bilateral casts due to upper arm fractures is not the first task that the AP should complete because it is not critical or life-threateninG. The client can wait until after breakfast to receive assistance with feedinG.
Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast is the first task that the AP should complete because it is essential and priority. The client needs to have their blood glucose level checked before receiving insulin to prevent hypoglycemia or hyperglycemiA.
Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is not the first task that the AP should complete because it is not important or necessary. The client can use other alternatives such as paper towels or napkins until they get more tissues.
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