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 ["B","E"]

Explanation

Choice A reason: Assessing the mucous membranes can provide useful information about the client’s overall hydration status. Checking for signs of dehydration, such as dry or sticky mucous membranes, can indicate whether the client may need additional fluids or intervention. However, this assessment does not directly address the issue of decreased urine output in the catheter, which might be due to a blockage or mechanical issue with the catheter itself.
Choice B reason: Ensuring that the catheter tubing is straight is crucial because any kinks or bends in the tubing can obstruct the flow of urine, leading to decreased urine output. This is a simple yet essential step that can be quickly performed by the practical nurse to rule out mechanical obstruction as the cause of the problem. By straightening the tubing, the nurse can help restore proper urine flow without the need for further invasive interventions.
Choice C reason: Auscultating lung sounds is an important assessment to determine if the client has any respiratory complications, such as fluid overload or pneumonia, which can sometimes occur post-transplant. While this is a critical assessment for overall health, it does not directly address the immediate issue of decreased urine output in the catheter. It is important to prioritize assessments that are directly related to the symptom being observed.
Choice D reason: Determining the dryness of bed linens can help assess if there has been any urine leakage around the catheter site or if the catheter is not functioning properly. Wet bed linens might indicate that the urine is bypassing the catheter or that there is a leak in the system. However, this assessment alone may not provide enough information to address the decreased urine output and should be combined with other assessments like ensuring the catheter tubing is straight.
Choice E reason: Irrigating the catheter to assess patency is a direct and immediate action that can help identify if the catheter is blocked. If there is resistance during irrigation, it indicates that the catheter may be obstructed, and further action is required to clear the blockage. This assessment can help resolve the issue of decreased urine output and is a practical step before notifying the charge nurse, as it provides a clear indication of the catheter's functionality.

A. Administer a prescribed analgesic. B. Measure the client's temperature. C. Initiate contact isolation precautions. D. Apply cool, wet compresses to the lesions.

Correct Answer is C

Explanation

Choice A reason: Administering a prescribed analgesic is important for managing the client's pain and improving their comfort. However, before addressing the client's pain, it is crucial to ensure that appropriate infection control measures are in place. Herpes zoster (shingles) is a contagious condition, especially when there are draining lesions. The first priority is to prevent the spread of the infection to other clients and healthcare workers.
Choice B reason: Measuring the client's temperature is important for monitoring for signs of systemic infection, such as fever. While this is a necessary assessment, it is not the most immediate priority. Ensuring that appropriate isolation precautions are in place takes precedence to prevent the transmission of the infection.
Choice C reason: Initiating contact isolation precautions is the most critical action to take first. Herpes zoster can be spread through direct contact with the fluid from the lesions. Implementing contact isolation precautions, such as wearing gloves and gowns, and placing the client in a private room, helps to contain the infection and protect others. This is the first step in managing the client's condition and ensuring a safe environment for all.
Choice D reason: Applying cool, wet compresses to the lesions can help soothe the affected area and provide some relief from the pain and discomfort associated with herpes zoster. However, this is not the immediate priority. The first action should be to implement isolation precautions to prevent the spread of the infection. Once isolation measures are in place, the nurse can then focus on providing symptomatic relief.

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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

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 ["B","E"]

Explanation

The practical nurse (PN) is caring for a client admitted with a diagnosis of herpes zoster. The client has draining lesions and reports that the affected area is painful. Which action should the PN take first?

Correct Answer is C

Explanation

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