The practical nurse (PN) is assisting with the admission of a client with complications of left- sided heart failure. Which focused assessment should the PN implement first?

Heart sounds

Mood and affect

Chest pain

Bilateral lung sounds

Answer and Explanation

The Correct Answer is D

The correct answer is choice D - Bilateral lung sounds.

Choice A rationale:

Heart sounds. While assessing heart sounds is crucial, the question specifically mentions complications of left-sided heart failure, which primarily affects the lungs. Therefore, assessing lung sounds is a higher priority in this situation.

Choice B rationale:

Mood and affect. While assessing the client's mood and affect is important for holistic care, it is not the most critical assessment to implement first in the case of left-sided heart failure complications.

Choice C rationale:

Chest pain. Although chest pain may be a symptom of left-sided heart failure complications, assessing bilateral lung sounds takes precedence as it directly relates to the client's respiratory status.

Choice D rationale:

Bilateral lung sounds. In left-sided heart failure, fluid can accumulate in the lungs, leading to pulmonary congestion and impaired gas exchange. Therefore, assessing lung sounds helps identify any respiratory distress early on, allowing prompt intervention and prevention of further complications.

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Correct Answer is B

Explanation

Choice A rationale:

While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.

Choice C rationale:

Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.

Choice D rationale:

Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.

A. Heating pad B. Body lotion C. Soft blanket D. Moist clothes

Correct Answer is C

Explanation

The correct answer is Choice C. Soft blanket.

Choice A rationale:

A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.

Choice B rationale:

The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.

Choice C rationale:

The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.

Choice D rationale:

Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.

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The practical nurse (PN) is assisting with the admission of a client with complications of left- sided heart failure. Which focused assessment should the PN implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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