a nurse is assessing a client with a history of heart failure which of the following findings should the nurse monitor
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A nurse is assessing a client with a history of heart failure. Which of the following findings should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Peripheral edema. In heart failure, the heart's inability to pump effectively can lead to fluid backup, causing swelling in the extremities, known as peripheral edema. Monitoring for peripheral edema is crucial as it is a common sign of worsening heart failure. Choices A, C, and D are incorrect because increased energy, elevated heart rate, and improved lung sounds are not typical findings in heart failure. Increased energy is not usually associated with heart failure, an elevated heart rate may occur as a compensatory mechanism but is not a direct sign of heart failure, and improved lung sounds are not expected in heart failure which often presents with crackles or wheezes due to pulmonary congestion.

2. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?

Correct answer: B

Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.

3. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

Correct answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

4. A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?

Correct answer: C

Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals. Baby oil (Choice A) is not recommended as it may not provide a sufficient barrier to prevent adherence. Antibiotic ointment (Choice B) is not typically used for this purpose and can sometimes cause irritation. Alcohol wipes (Choice D) are too harsh for the sensitive skin of a newborn and can cause irritation.

5. A nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury (TBI). What finding should the nurse recognize as a complication and report to the provider?

Correct answer: D

Rationale: Unequal pupils are a sign of increased intracranial pressure or worsening brain injury, indicating a serious complication that requires immediate medical attention. Hypertension, vomiting, and drainage from the ear are not typically associated with minor traumatic brain injury complications; therefore, they are not the priority findings to report to the provider.

Similar Questions

A client with rheumatoid arthritis is taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?
A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?
A healthcare professional is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL would the healthcare professional administer per dose?
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. The client reports heavy bleeding and passing large clots. What is the priority action for the nurse to take?
When assessing a client with a small bowel obstruction, what finding should a nurse expect?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses