a nurse is assessing a client with a history of heart failure which of the following findings should the nurse monitor
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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 caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. Which of the following client statements indicates a need for further teaching?

Correct answer: A

Rationale: Clients should be instructed to complete the entire course of antibiotics, even if they start feeling better, to prevent antibiotic resistance and recurrence of infection.

3. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for one week. Which of the following should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. Wearing a dosimeter helps monitor the cumulative radiation exposure of healthcare workers, ensuring their safety during care. Removing dirty linens, limiting visitor time, and maintaining a distance from the client are not directly related to radiation safety measures and are not necessary in this scenario.

4. A healthcare professional is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client?

Correct answer: C

Rationale: A BMI of 25-29.9 is considered overweight. Therefore, a BMI of 25 correlates with an overweight client. A BMI of 18.5-24.9 indicates a healthy weight. Choices A, B, and D are incorrect as they fall into the healthy weight or obese categories, not overweight.

5. A nurse is preparing to administer a dose of ampicillin. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is to 'Check for penicillin allergy.' Before administering ampicillin, it is crucial to assess the patient for any history of penicillin allergy. This is essential to prevent an adverse allergic reaction, as ampicillin belongs to the penicillin class of antibiotics. Administering ampicillin with food (Choice A) is not a standard requirement and does not impact its effectiveness. Monitoring liver function (Choice C) is not directly related to the immediate pre-administration assessment for ampicillin. Administering ampicillin intramuscularly (Choice D) is not typically the route of administration for this antibiotic, as it is usually given intravenously or orally.

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