a nurse is planning care for a client who has chronic renal failure which of the following dietary instructions should the nurse provide
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?

Correct answer: C

Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.

2. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.

3. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

4. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.

5. 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.

Similar Questions

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following should the nurse assess for?
A client is prescribed tramadol for pain management. Which of the following should the nurse educate the client about?
A nurse is caring for four clients. Which client should the nurse assess first?
A nurse is providing discharge instructions to a client following a below-the-knee amputation. Which of the following instructions should the nurse include?

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