The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?
Inspect for sacral edema.
Measure urinary output.
Auscultate all lung fields.
Check mental acuity.
Check mental acuity.
The Correct Answer is C
When assessing an older client with left-sided heart failure (HF), the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. Left-sided heart failure is characterized by the inability of the left ventricle to effectively pump blood, leading to fluid accumulation in the lungs. Auscultating all lung fields allows the PN to assess for the presence of abnormal lung sounds such as crackles, indicating pulmonary congestion.
In summary, when assessing an older client with left-sided heart failure, the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. This allows for the detection of abnormal lung sounds associated with pulmonary congestion, a hallmark sign of left-sided heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer is: a. Paper tape, b. Small gauze pad, and d. Exam gloves.
Choice A: Paper tape
Reason: Paper tape is used to secure the gauze pad over the site after the saline lock is removed. It is gentle on the skin and helps to keep the gauze in place, preventing any bleeding or infection at the site.
Choice B: Small gauze pad
Reason: A small gauze pad is essential to apply pressure to the site after the saline lock is removed. This helps to stop any bleeding and provides a clean, sterile covering for the site.
Choice C: Sterile gloves
Reason: Sterile gloves are not necessary for this procedure. Exam gloves are sufficient to maintain cleanliness and prevent infection during the removal of the saline lock.
Choice D: Exam gloves
Reason: Exam gloves are used to maintain hygiene and prevent infection during the procedure. They provide adequate protection for both the nurse and the patient.
Choice E: Three mL syringe
Reason: A three mL syringe is not required for the removal of a saline lock. Syringes are typically used for flushing the saline lock, not for its removal.
Correct Answer is C
Explanation
This is the correct answer because it is the most important and relevant action that the PN should do for a postoperative patient with a PCA machine. A PCA machine is a computerized device that allows the patient to self-administer a preset dose of pain medication, usually an opioid, by pressing a buton. The PCA machine is attached to an intravenous (IV) line that delivers the medication directly into the bloodstream. The PCA machine can provide effective and individualized pain relief for postoperative patients, as well as increase their sense of control and satisfaction¹².
The PN should assess the pain management response of the postoperative patient with a PCA machine by monitoring their pain level, vital signs, oxygen saturation, sedation level, and side effects. The PN should use a valid and reliable pain scale, such as the numeric rating scale (NRS) or the visual analog scale (VAS), to measure the patient's pain intensity and relief. The PN should also check the settings and functioning of the PCA machine, such as the dose, lockout interval, and limit. The PN should document and report the patient's pain management response and any problems or complications with the PCA machine to the health care provider.
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