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
Explanation
The client's statements suggest significant distress, feelings of being a burden, and a sense of hopelessness related to their obsessive-compulsive disorder (OCD). Given the severity of these statements, it is crucial for the PN to assess the client's risk of suicide or self-harm. Asking directly about suicidal thoughts or considering suicide as an option allows the PN to evaluate the immediate safety of the client and take appropriate actions to ensure their well-being.
While the other options may also provide relevant information, they are not as critical as assessing the client's risk of suicide.
B. Questioning about which rituals are most often used to reduce anxiety can help gather information about the client's specific OCD symptoms and coping mechanisms.
C. Determining what makes the client think people are laughing can provide insight into their perception of how others view them, but it may not address the immediate risk of harm.
D. Asking about the impact of obsessions and compulsions on sleep can help assess the client's overall functioning, but it does not address the immediate risk of suicide.
Correct Answer is A
Explanation
A client with continuous urinary bladder irrigation via a 3-way catheter: This task requires specialized knowledge and skill to ensure proper management of the irrigation process, monitoring for complications, and adjusting the irrigation rate as needed. It falls within the scope of practice of the PN, who has the necessary training and expertise.
B. A client with urinary urgency and incontinence who is asking for a bedpan: This task can be safely and appropriately assigned to the UAP. Assisting the client with using a bedpan for voiding is a basic care task that does not require specialized nursing knowledge or skills.
C. A client with a full urinary bedside drainage unit after receiving a diuretic: Emptying a full urinary bedside drainage unit is a task that can be assigned to the UAP. It involves routine emptying and documentation of the drainage bag and does not require specialized nursing knowledge or skills.
D. A client with paraplegia who needs a urinary condom-catheter change: This task requires specialized knowledge and skill to perform a sterile procedure, ensure proper placement and securement of the condom catheter, and assess for any complications. It falls within the scope of practice of the PN, who has the necessary training and expertise.
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