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 B
Explanation
Hypoglycemia occurs when blood glucose levels drop below normal levels. It is commonly associated with diabetes mellitus and can result from various factors such as excessive insulin or oral hypoglycemic medication, delayed or missed meals, increased physical activity, or alcohol consumption.
Tremors, or shaking hands, are one of the early signs of hypoglycemia. They can occur due to the brain's response to low blood glucose levels. Other early signs of hypoglycemia may include sweating, palpitations, anxiety, hunger, and weakness.
A. Polyuria, or excessive urination, is not typically associated with hypoglycemia. It is more commonly seen in conditions such as hyperglycemia or diabetes insipidus.
C. Bradycardia, or a slow heart rate, is not a characteristic sign of hypoglycemia. It can occur in some cases of severe hypoglycemia, but it is not an early sign.
D. Difficulty swallowing is not directly related to hypoglycemia. It may be caused by other factors such as neurological or muscular conditions, esophageal disorders, or structural abnormalities in the throat or esophagus.
Correct Answer is D
No explanation
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