a nurse is providing teaching to a client who has a new diagnosis of heart failure which of the following instructions should the nurse include
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. A client with a new diagnosis of heart failure is receiving teaching from a nurse. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B. Weighing oneself daily is crucial in monitoring fluid retention, a key aspect in managing heart failure. This helps in detecting early signs of fluid buildup, prompting timely interventions. Choice A is incorrect as the recommended sodium intake for heart failure clients is usually lower, around 2-3 grams daily. Choice C is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice D is incorrect as clients with heart failure should consult healthcare providers before significantly altering their physical activity levels.

2. A nurse is providing discharge teaching to a client who has a new prescription for lithium. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client prescribed lithium is to drink at least 2 liters of water each day. This is important to prevent dehydration and reduce the risk of lithium toxicity. Option A is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Option B is unrelated to lithium and is more applicable to clients taking MAOIs. Option D is incorrect as lithium is typically taken in divided doses throughout the day to maintain therapeutic levels.

3. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.

4. What is the initial intervention for a patient experiencing an allergic reaction?

Correct answer: A

Rationale: The correct answer is to administer antihistamines as the initial intervention for a patient experiencing an allergic reaction. Antihistamines work to block the effects of histamine, a substance released during an allergic reaction, helping to relieve symptoms such as itching, swelling, and hives. Corticosteroids (Choice B) are sometimes used in severe cases to reduce inflammation, but they are not the first-line treatment for an allergic reaction. Administering oxygen (Choice C) may be necessary if the patient is having difficulty breathing, but it is not the first intervention. IV fluids (Choice D) are typically given for conditions like dehydration or shock, not as the primary intervention for an allergic reaction.

5. A nurse is assessing a school-age child with a urinary tract infection. What symptom should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Enuresis. Enuresis, which refers to involuntary urination, is a common symptom of urinary tract infections in children. Periorbital edema (choice A) is more commonly associated with conditions like nephrotic syndrome. Decreased frequency of urination (choice B) is not typically seen in urinary tract infections, as these infections often present with increased frequency. Diarrhea (choice D) is not a typical symptom of a urinary tract infection.

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