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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Driving a car is an activity that should be limited until after the first postoperative visit. Postoperative clients might experience discomfort, dizziness, or medication side effects that can impair their ability to drive safely. The stress and physical demands of driving can also affect the healing process, so it's important to avoid this activity until the healthcare provider gives clearance.
Choice B reason: Eating high-fiber foods is generally encouraged postoperatively to prevent constipation and ensure smooth bowel movements. There is no reason to limit high-fiber foods after a transurethral prostatectomy unless otherwise specified by the healthcare provider.
Choice C reason: Kegel exercises can help strengthen the pelvic floor muscles and are often recommended after prostate surgery to improve bladder control. However, it is important to follow the healthcare provider's guidance on when to start these exercises and how frequently they should be done.
Choice D reason: Walking around the house is a light activity that can aid in recovery by promoting circulation and preventing blood clots. It is usually recommended to start light activity soon after surgery, unless contraindicated by the healthcare provider.

A. "Hair loss is not usually permanent, but the color and texture may change when it grows back." B. "We can never tell. People with cancer react differently to chemotherapy." C. "It is likely that your hair will grow back, but if it does not there are very good wigs available." D. "It depends on the amount of drug you receive with your particular treatment."

Correct Answer is A

Explanation

Choice A reason: Providing reassurance that hair loss is not usually permanent offers the client some comfort during a challenging time. Informing her that the color and texture may change when it grows back prepares her for potential differences in her hair's appearance post-chemotherapy. This response acknowledges the temporary nature of chemotherapy-induced hair loss while also being honest about the possibility of changes, which helps manage the client's expectations effectively.
Choice B reason: Stating that "people with cancer react differently to chemotherapy" is true, but it is not the most supportive or informative response. It may leave the client feeling uncertain and anxious about the outcome. Providing more specific information about hair regrowth, as in choice A, is more helpful in addressing the client's concerns and providing reassurance.
Choice C reason: While acknowledging that wigs are available is practical, focusing on the possibility that hair might not grow back can be disheartening for the client. It is important to offer hope and positivity where possible, and emphasizing the usual pattern of hair regrowth, as in choice A, is a more supportive approach. If the client does have concerns about wigs, this can be discussed separately.
Choice D reason: Indicating that hair regrowth depends on the amount of drug received is somewhat accurate but lacks the reassurance and positivity provided in choice A. It is important to give the client a clearer understanding that, in most cases, hair loss from chemotherapy is temporary, and hair will generally grow back. This helps alleviate some of the stress associated with the treatment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 is recovering from a transurethral prostatectomy. Which activity should the practical nurse (PN) reinforce with the client to limit until after the first postoperative visit?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

A male client who recently had a myocardial infarction tells the practical nurse (PN) that he refuses to give up his habit of smoking two packs of cigarettes daily. Which intervention(s) should the PN implement? Select all that apply.

A client with Crohn's disease has a serum sodium level of 130 mEq/L (130 mmol/L). Which foods should the practical nurse (PN) encourage the client to eat? Reference Range: Sodium: 136 to 145 mEq/L (136 to 145 mmol/L)

A client is recovering from a transurethral prostatectomy. Which activity should the practical nurse (PN) reinforce with the client to limit until after the first postoperative visit?

A client with breast cancer who received chemotherapy two weeks ago returns to the clinic for follow-up. Which priority follow-up assessment should the practical nurse (PN) anticipate for this client?

The practical nurse (PN) is preparing a client for a mammogram. Which instruction should the PN provide the client?

The practical nurse (PN) is monitoring a client who was admitted following a motor vehicle collision (MVC). The PN is unable to auscultate breath sounds on the left side, and the healthcare provider is notified. While awaiting the arrival of the healthcare provider, which action should the PN take?

A client with diabetes mellitus is admitted with an infected foot pressure injury. During a routine assessment, the practical nurse (PN) notes a pattern of deep, rapid respirations and a fruity breath odor. Which action should the PN take first?