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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Use a client-specific stethoscope.
Indicated: Using a client-specific stethoscope helps prevent the spread of MRSA between patients. Each client should have dedicated equipment to reduce cross-contamination.
B. Wipe the medication cart with bleach after bringing it into the room.
Not Indicated: While disinfection of surfaces is important, the cart should be cleaned according to hospital protocol, which may involve different cleaning agents. Bleach is not typically used for medication carts and might not be the standard protocol.
C. Measure the client's temperature with a disposable thermometer.
Indicated: Using a disposable thermometer or single-use covers for thermometers prevents the transmission of MRSA to other patients. This practice helps maintain infection control.
D. Change gloves between different clients.
Indicated: Gloves should be changed between patients to prevent the spread of MRSA. This is a standard infection control practice to avoid cross-contamination.
E. Pad the client's side rails with clean linens.
Not Indicated: While padding the side rails may be done for client comfort or safety, it does not specifically address the control of MRSA spread and is not a direct infection control measure for MRSA.
Correct Answer is A,C,B,D
Explanation
A. Informing the client of the purpose of the medication is the first step. This action ensures that the client understands why they are receiving the medication and what it is intended to do.
C. Putting on a clean pair of gloves is the next step to maintain hygiene and prevent contamination while handling the medication and applying the patch.
B. Placing the patch on a new area of cleansed skin follows glove application. Ensuring that the skin is clean and that a new site is used prevents irritation and ensures the effectiveness of the medication.
D. Documenting the application in the electronic medication record is the final step to complete the medication administration process. This ensures that the medication administration is recorded accurately for future reference and compliance.
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