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
Chest pain
Bilateral lung sounds
Mood and affect
The Correct Answer is C
c) Bilateral lung sounds.
Explanation:
When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.
While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admited with complications of left-sided heart failure.
The other options are considered incorrect because they are not the priority assessments when admitting a client with complications of left-sided heart failure.
Option a) Heart sounds: While assessing heart sounds is important in evaluating cardiac function, the priority in this scenario is to assess for pulmonary congestion and impaired gas exchange. Assessing bilateral lung sounds allows the practical nurse to gather immediate information about the client's respiratory status and the presence of fluid in the lungs.
Option b) Chest pain: Chest pain is a significant symptom that should be assessed promptly, as it could indicate various cardiac or respiratory conditions. However, in this specific scenario, the priority is to assess for signs of pulmonary congestion, which can have a more immediate impact on the client's respiratory function.
Option d) Mood and affect: Assessing the client's mood and affect is important for a comprehensive assessment of their emotional well-being. However, when admitting a client with complications of left- sided heart failure, the priority is to assess their physical condition, particularly the respiratory status, to address any immediate concerns related to pulmonary congestion and impaired gas exchange.
 |
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: "Move objects away from the client." This instruction should be included in the teaching because it can prevent injury and protect the client from harm during a seizurE.
Choice B reason: "Restrain the client." This instruction should not be included in the teaching because it can cause injury and increase agitation and anxiety for the client during a seizurE.
Choice C reason: "Place the client on his back." This instruction should not be included in the teaching because it can increase the risk of aspiration and airway obstruction for the client during a seizurE.
Choice D reason: "Insert a padded tongue blade into the client's moutH." This instruction should not be included in the teaching because it can cause injury and choking for the client during a seizurE.
Correct Answer is B
Explanation
Choice A reason: Performing carotid massage is not an appropriate action for the nurse to take because it can worsen the client's condition by decreasing the blood flow to the brain, causing further ischemia or hemorrhagE. Carotid massage is a technique that involves applying pressure to the carotid artery to slow down the heart rate, which can be dangerous for clients who have a strokE.
Choice B reason: Calling for help is an appropriate action for the nurse to take because it can initiate the rapid response team and activate the stroke protocol, which can improve the client's outcome and survival. The nurse should also assess the client's vital signs, neurological status, and time of symptom onset, and report them to the health care provider.
Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for the nurse to take because it can increase the risk of aspiration and pneumonia, which can complicate the client's recovery and prognosis. The nurse should avoid giving anything by mouth to the client until their swallowing ability is evaluated by a speech therapist or a swallow study.
Choice D reason: Administering thrombolytics is not an appropriate action for the nurse to take because it requires a physician's order and confirmation of the type and cause of stroke by a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. Thrombolytics are drugs that dissolve blood clots and restore blood flow, which can be beneficial for clients who have ischemic stroke, but harmful for clients who have hemorrhagic strokE.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today