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 D
Explanation
A. Administering half of the missed dose is not generally recommended because it could lead to inconsistent drug levels and potential for breakthrough seizures. The standard practice is to follow the dosing schedule unless otherwise instructed by the healthcare provider.
B. Giving the missed dose with the next scheduled dose may lead to double dosing and could increase the risk of side effects or toxicity. The missed dose should be addressed as soon as possible but not in combination with the next dose.
C. Withholding the missed dose unless seizure activity occurs could put the client at risk for seizures. Anticonvulsants should be administered as per the prescribed schedule to maintain therapeutic drug levels and prevent seizures.
D. Administering the missed dose as soon as possible is the correct approach, following standard guidelines for missed medications. The missed dose should be given promptly unless it is close to the time of the next dose, in which case the next dose should be given as scheduled.
Correct Answer is A
Explanation
A. The submandibular lymph nodes are located beneath the lower jaw, in the area where the jawbone meets the neck. This is the correct location to palpate for enlargement of these lymph nodes.
B. The temporal bone is located on the side of the head, not relevant to the location of the submandibular lymph nodes. Palpation for these nodes occurs beneath the lower jaw, not near the temporal bone.
C. Lateral to the trachea refers to the location of other lymph nodes such as the anterior cervical or supraclavicular nodes, not the submandibular nodes. Submandibular nodes are specifically beneath the jaw.
D. Above the upper jaw does not correspond to the location of the submandibular lymph nodes. These nodes are palpated beneath the lower jaw, making this option incorrect.
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