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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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 teaching a client who is lactose intolerant about dietary choices. Which food should the nurse recommend to increase calcium intake?

Correct answer: A

Rationale: The correct answer is A: Spinach. Spinach is rich in calcium, making it a suitable choice for individuals with lactose intolerance who need to avoid dairy products. Peanut butter, ground beef, and carrots are not significant sources of calcium compared to spinach, and therefore, not the best recommendation for increasing calcium intake in lactose-intolerant individuals.

3. A healthcare professional is assessing a client for signs of dehydration. Which of the following findings should the healthcare professional look for?

Correct answer: B

Rationale: Dry mucous membranes are a classic sign of dehydration. In dehydration, the body loses more water than it takes in, leading to dryness of mucous membranes like the mouth and throat. Edema (choice A) is swelling caused by excess fluid trapped in the body's tissues, which is not a typical sign of dehydration. Weight gain (choice C) is also not a common sign of dehydration; in fact, dehydration usually leads to weight loss. Increased urination (choice D) is more indicative of conditions like diabetes or diuretic use, not dehydration.

4. A nurse in an urgent-care clinic is collecting admission history from a client who is 16 weeks gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection?

Correct answer: B

Rationale: Bacterial vaginosis often presents with a profuse, milky white discharge and a characteristic fishy odor, without significant inflammation, hematuria, or fever. Choice A, frequency, and dysuria are more indicative of a urinary tract infection. Choice C, hematuria, is associated with conditions like urinary tract infections or kidney problems. Choice D, low-grade fever, is not a typical symptom of bacterial vaginosis.

5. What can cause a low pulse oximetry reading?

Correct answer: C

Rationale: Inadequate peripheral circulation can cause a low pulse oximetry reading by limiting blood flow to the area being measured, leading to inaccurate oxygen saturation readings. Hyperthermia (choice A) is an elevated body temperature and does not directly affect pulse oximetry readings. An increased hemoglobin level (choice B) would actually lead to higher oxygen-carrying capacity in the blood, resulting in normal or increased pulse oximetry readings. Low altitudes (choice D) typically do not cause low pulse oximetry readings unless there are other underlying conditions affecting oxygen levels.

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