a nurse is caring for a client who has congestive heart failure which of the following prescriptions from the provider should the nurse anticipate
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is caring for a client who has congestive heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

Correct answer: C

Rationale: The correct answer is C. Enalapril is an ACE inhibitor commonly prescribed for clients with congestive heart failure to help reduce blood pressure and fluid overload. Option A is incorrect as in congestive heart failure, a lower respiratory rate could be a sign of worsening condition and needs immediate attention rather than waiting to call the provider. Option B is incorrect as administering a large IV bolus of sodium chloride could exacerbate fluid overload in a client with heart failure. Option D is incorrect as a pulse rate lower than 80/min may not necessarily indicate a problem in a client with congestive heart failure.

2. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?

Correct answer: A

Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.

3. A nurse is caring for a client with hepatic encephalopathy. Which food selection indicates an understanding of dietary teaching?

Correct answer: C

Rationale: The correct answer is C: 'Rice with black beans.' Clients with hepatic encephalopathy should limit animal proteins due to their high ammonia content, which can exacerbate symptoms. Plant-based proteins like beans are preferred as they help reduce ammonia levels. Choices A, B, and D contain animal proteins that are not ideal for clients with hepatic encephalopathy.

4. A nurse is preparing to administer a blood transfusion. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct first action the nurse should take when preparing to administer a blood transfusion is to verify the blood type and crossmatch. This step is crucial to ensure compatibility and prevent transfusion reactions. Obtaining the client's consent is important but should follow the verification process. Taking baseline vital signs is necessary before starting the transfusion, but confirming compatibility takes precedence. Priming the IV with normal saline is a step done before starting the transfusion, after ensuring blood compatibility.

5. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

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