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?
Measure urinary output.
Auscultate all lung fields.
Check mental acuity.
Inspect for sacral edema.
The Correct Answer is B
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.
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Related Questions
Correct Answer is C
Explanation
A. Feeling for a carotid pulse is part of the assessment process but is not the first step in responding to an unresponsive client. Immediate action to summon emergency help is the priority.
B. Bringing a glucometer to the room is not appropriate at this stage. While checking blood glucose might be necessary, the first step is to get emergency assistance.
C. Obtaining emergency help is the most critical first step when encountering an unresponsive client. Emergency help ensures that appropriate interventions are initiated promptly.
D. Checking the blood pressure is part of a complete assessment but is not the most urgent action. The priority is to call for emergency assistance rather than performing further assessments.
Correct Answer is B
Explanation
A. Reviewing the prognosis for the spouse does not address the immediate concern about the influenza vaccination’s impact on the spouse’s health.
B. Explaining that the influenza vaccination will actually help reduce the risk of transmission of influenza to the spouse undergoing chemotherapy addresses the client’s concern and provides accurate information.
C. Planning the vaccination for a day when the spouse is not receiving chemotherapy does not resolve the underlying issue of the vaccination’s effectiveness and safety.
D. Determining when the spouse will finish chemotherapy is not relevant to the immediate concern of the vaccination and its effects on the spouse’s health.
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