the nurse is developing a critical pathway for congestive heart failure chf which components are essential to include select all that apply

ATI RN

ATI Leadership Proctored Exam 2019 Quizlet

1. The healthcare provider is developing a critical pathway for congestive heart failure (CHF). Which components are essential to include? (Select all that apply.)

A. Expected length of stay
B. Assigned healthcare team
C. Patient outcomes
D. Medical history

Correct answer: C

Rationale: In developing a critical pathway for congestive heart failure (CHF), it is essential to include patient outcomes. Patient outcomes help guide the care plan and ensure that interventions are effective. The expected length of stay is crucial to plan for resources but is not directly related to the critical pathway components. While the assigned healthcare team is important for care delivery, it is not a standard component of a critical pathway. Medical history is valuable for understanding the patient's background but is not a core component of a critical pathway.

2. After change-of-shift report, which patient should the nurse assess first?

A. 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon
B. 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL
C. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa
D. 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

Correct answer: C

Rationale: The patient with hyperosmolar hyperglycemic syndrome who presents with poor skin turgor and dry oral mucosa requires immediate attention. These signs indicate severe dehydration and potential electrolyte imbalances, which can lead to serious complications. Assessing this patient first allows for prompt intervention and monitoring to stabilize their condition. Choice A is less urgent as the patient has possible dawn phenomenon, which is a common early-morning rise in blood glucose levels. Choice B, with a blood glucose reading of 230 mg/dL, indicates hyperglycemia but does not present with signs of severe dehydration like the patient in choice C. Choice D, with peripheral neuropathy and foot pain, is important but not as urgent as addressing severe dehydration and electrolyte imbalances in the patient with hyperosmolar hyperglycemic syndrome.

3. What information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?

A. Select flat-soled leather shoes
B. Apply heating pads on a low temperature.
C. Avoid using callus remover for corns or calluses.
D. Refrain from soaking feet in warm water for an hour each day.

Correct answer: A

Rationale: The correct answer is to select flat-soled leather shoes. Patients with peripheral arterial disease, type 2 diabetes, and sensory neuropathy are at risk for foot injuries due to decreased sensation and poor circulation. Flat-soled leather shoes can help prevent injuries and provide adequate support without causing pressure points. Choice B is incorrect as using heating pads can lead to burns for patients with sensory neuropathy. Choice C is wrong because using callus remover may lead to skin damage for patients with compromised circulation. Choice D is not recommended as soaking feet in warm water can further damage the skin due to decreased sensation.

4. Which of the following best describes the ethical concept of values?

A.
B. Values are learned through family systems.
C. Values are organized ways of thinking about the meaning of life.
D. Values determine the rightness or wrongness of behavior.

Correct answer: A

Rationale: Values are how individuals feel about ideas, situations, and concepts.

5. When a client is receiving pain medication through a PCA pump, which of the following actions should the nurse take?

A. Educate the family not to push the button for the client while the client is asleep.
B. Explain to the client that vital signs will be monitored regularly due to being on a PCA pump.
C. Instruct the client to push the button only when pain is above a 7 on a scale of 0 to 10.
D. Adjust the basal rate and decrease the lock-out interval time if the client's pain level is too high.

Correct answer: D

Rationale: When a client is receiving pain medication through a PCA pump, it is essential to adjust the settings if their pain level is not adequately controlled. Increasing the basal rate and shortening the lock-out interval time can help manage the client's pain more effectively. This adjustment should be made by the healthcare provider based on the client's pain assessment and response to the current settings. It is crucial to individualize the PCA pump settings to optimize pain management for each client. Choices A, B, and C are incorrect because educating the family not to push the button, explaining vital sign monitoring, and setting a specific pain level for button pushing are not direct actions the nurse should take to adjust the PCA pump settings for effective pain management.