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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hydrocortisone is a corticosteroid that can cause fluid retention and increase blood pressure in some individuals. It is important for the PN to monitor the client's blood pressure and educate them about this potential side effect.
Choice B reason: Tiotropium bromide is a bronchodilator used to manage asthma and chronic obstructive pulmonary disease (COPD). While it is not commonly associated with increasing blood pressure, the PN should still be aware of any potential side effects and monitor the client's blood pressure.
Choice C reason: Ethinyl estradiol/norethindrone is a combination oral contraceptive that contains estrogen and progestin. Estrogen can cause blood vessels to constrict, leading to an increase in blood pressure. The PN should educate the client about this potential side effect and monitor their blood pressure regularly.
Choice D reason: Pseudoephedrine is a decongestant that can cause vasoconstriction and increase blood pressure. It is important for the PN to inform the client about this potential side effect and monitor their blood pressure closely.
Choice E reason: Albuterol sulfate is a bronchodilator used to relieve asthma symptoms. While it can cause some cardiovascular side effects, such as increased heart rate, it is not typically associated with a significant increase in blood pressure. The PN should still monitor the client's blood pressure and be aware of any potential side effects.
Correct Answer is B
Explanation
Choice A reason: There is no specific requirement to avoid upper body exercise on the day of a mammogram. While vigorous exercise might cause some temporary muscle discomfort, it does not impact the results of the mammogram. The primary concern is ensuring clear imaging of the breast tissue, not the effects of exercise.
Choice B reason: Clients are instructed not to use underarm deodorant on the day of a mammogram because deodorants, antiperspirants, powders, or lotions can contain metallic particles that may appear on the mammogram images as white spots. These spots can be mistaken for calcifications, leading to potential misinterpretation of the results or the need for additional imaging. Ensuring the client avoids using these products helps achieve the clearest possible images for accurate diagnosis.
Choice C reason: Avoiding aspirin for one week prior to a mammogram is not a standard instruction. Aspirin can affect blood clotting, and such instructions are typically given before surgical procedures rather than imaging tests. There is no direct impact of aspirin on the mammogram process or results.
Choice D reason: There is no requirement to avoid eating or drinking for 6 hours before a mammogram. This instruction is more relevant for procedures that involve anesthesia or sedation, where an empty stomach is necessary to reduce the risk of aspiration. Mammograms do not involve these risks, and clients can eat and drink as usual.
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