A female client who has been taking oral contraceptives for the past year comes into the clinic for an annual exam. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?

Breast tenderness.

Left calf pain.

Change in menstrual flow.

Weight gain of 5 pounds (2.3 kg).

Answer and Explanation

The Correct Answer is B

A. Breast tenderness is a common side effect of oral contraceptives and is generally not a cause for immediate concern unless accompanied by other symptoms.
B. Left calf pain is a significant finding that could indicate deep vein thrombosis (DVT), a serious condition requiring prompt evaluation and potential treatment to prevent complications such as pulmonary embolism.
C. A change in menstrual flow can occur with oral contraceptives but is usually less critical than other symptoms. It should be monitored but does not indicate an immediate problem.
D. A weight gain of 5 pounds is a relatively minor side effect and not as urgent as symptoms suggestive of a serious condition like DVT.

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Correct Answer is B

Explanation

A. Measure urinary output.
Measuring urinary output is important for monitoring fluid balance but is not the most critical intervention for assessing left-sided heart failure specifically.
B. Auscultate all lung fields.
Auscultating lung fields is crucial for assessing signs of pulmonary edema, a key symptom of left-sided heart failure. It provides direct information about the severity of the condition and guides further management.
C. Check mental acuity.
Checking mental acuity can be useful but is not the most critical intervention for managing left-sided heart failure. It is less directly related to evaluating the severity of heart failure compared to lung auscultation.
D. Inspect for sacral edema.
Inspecting for sacral edema is more relevant for right-sided heart failure. For left-sided heart failure, the priority is evaluating pulmonary symptoms, not peripheral edema.

A. Administer a dose of acetaminophen PRN per prescription. B. Monitor the child's oxygen saturation level via pulse oximeter. C. Encourage the child to drink adequate amounts of cool, clear liquids. D. Instruct the mother to play with the child for stimulation and distraction.

Correct Answer is B

Explanation

A. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.

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A female client who has been taking oral contraceptives for the past year comes into the clinic for an annual exam. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

Correct Answer is B

Explanation

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

Correct Answer is B

Explanation

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