A client with heart failure requests two more pillows to sleep with at night. Which area should the practical nurse (PN) evaluate when responding to the client's request?

Neuro vital signs.

Urinary output.

Blood pressure.

Breath sounds.

Answer and Explanation

The Correct Answer is D

Choice A reason: Evaluating neuro vital signs includes assessing the client's level of consciousness, pupil response, motor function, and other neurological indicators. While important for overall assessment, changes in neurological status are not the most immediate concern in the context of heart failure and the client's request for more pillows. The request may be related to orthopnea, a common symptom of heart failure where clients experience difficulty breathing while lying flat.
Choice B reason: Monitoring urinary output is crucial for assessing kidney function and fluid balance, especially in clients with heart failure. However, it does not directly address the client's symptom of needing more pillows to sleep, which is more likely related to respiratory discomfort. While maintaining adequate urinary output is important, it is not the primary assessment needed in this scenario.
Choice C reason: Blood pressure is a vital sign that needs regular monitoring in clients with heart failure, as it can indicate fluid status and cardiac function. However, the need for additional pillows to sleep is more directly related to respiratory issues rather than blood pressure alone. While important, it is not the primary focus in response to the client's specific request.
Choice D reason: Evaluating breath sounds is the most relevant assessment when a client with heart failure requests more pillows to sleep. This request often indicates orthopnea, where the client has difficulty breathing while lying flat due to fluid accumulation in the lungs (pulmonary congestion). By assessing breath sounds, the PN can detect signs of crackles, wheezing, or decreased air entry, which may indicate worsening heart failure or pulmonary edema. Prompt assessment and intervention are crucial to address respiratory distress and prevent further complications.

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Correct Answer is D

Explanation

Choice A reason: Facial pallor, particularly around the lips, could indicate anemia or poor perfusion, but it is not the most urgent finding in this context. Polycythemia vera typically involves an overproduction of red blood cells, which can actually result in a ruddy complexion rather than pallor. While pallor should be monitored, it does not require immediate reporting compared to other potential complications of polycythemia vera.
Choice B reason: An increased heart rate over the last 4 hours could be a sign of various conditions, such as dehydration, fever, or cardiovascular stress. However, in the context of polycythemia vera, it is not as immediately concerning as symptoms that might indicate thrombotic complications, which are a common and serious risk for these patients. Tachycardia should be monitored, but it is not the most critical finding needing immediate attention.
Choice C reason: Dark brown stools could indicate the presence of digested blood, suggesting gastrointestinal bleeding. While this is an important finding that requires further investigation, it is not as immediately life-threatening as signs of deep vein thrombosis (DVT) in a client with polycythemia vera. Bleeding risks do exist with this condition, but the urgency of DVT symptoms demands prompt intervention to prevent further complications, such as a pulmonary embolism.
Choice D reason: Right lower leg redness and edema are classic signs of deep vein thrombosis (DVT). Clients with polycythemia vera are at increased risk for thrombotic events due to the hyperviscosity of their blood. Reporting this finding immediately is critical, as DVT can lead to serious complications, including pulmonary embolism, which can be life-threatening. Early detection and intervention are essential in managing thrombotic risks in polycythemia vera patients.

A. Check mucous membranes. B. Ensure catheter tubing is straight. C. Auscultate lung sounds. D. Determine dryness of bed linens. E. Irrigate catheter to assess patency.

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: Checking mucous membranes can provide information about the client's hydration status. Dry mucous membranes can be a sign of dehydration, which may contribute to decreased urine output. This assessment is important to determine whether the client has adequate fluid balance.
Choice B reason: Ensuring that the catheter tubing is straight is essential to confirm that there are no kinks or obstructions that could be causing the reduced urine flow. Any obstruction in the catheter tubing could lead to a sudden decrease in urine output, and this check helps ensure patency.
Choice C reason: Auscultating lung sounds is crucial to assess for fluid overload or pulmonary complications, which can be associated with renal transplant patients. Abnormal lung sounds could indicate issues that may indirectly affect urine output and overall kidney function.
Choice D reason: Determining the dryness of bed linens helps assess whether the client might have experienced a leakage of urine outside the catheter system. If the bed linens are wet, it could indicate an issue with the catheter or bladder function that needs to be addressed.
Choice E reason: Irrigating the catheter to assess patency is a direct method to determine whether there is any blockage or obstruction in the catheter. This procedure helps ensure that the catheter is functioning correctly and allows for appropriate urine drainage.

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A client with heart failure requests two more pillows to sleep with at night. Which area should the practical nurse (PN) evaluate when responding to the client's request?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is completing a focused assessment of a client who was admitted yesterday with polycythemia vera. Which finding should the PN report to the charge nurse immediately?

Correct Answer is D

Explanation

A client who received a renal transplant two weeks ago is experiencing a rapid and sudden decrease in urine output in the catheter. Which assessment(s) should the practical nurse (PN) complete before notifying the charge nurse? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

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