a nurse is assessing a client who has left sided heart failure which of the following findings should the nurse expect a nurse is assessing a client who has left sided heart failure which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Exit Exam 2023 Quizlet

1. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Jugular vein distention. In left-sided heart failure, the left ventricle fails to efficiently pump blood to the body, causing increased pressure in the pulmonary circulation. This increased pressure can lead to symptoms like jugular vein distention, as blood backs up in the pulmonary circulation and causes congestion. Choices A, B, and D are incorrect: Peripheral edema is more commonly associated with right-sided heart failure, cough with frothy sputum is a sign of pulmonary edema which can occur in left-sided heart failure but is not as specific as jugular vein distention, and dependent edema is also more indicative of right-sided heart failure due to fluid retention and increased venous pressure in the systemic circulation.

2. The healthcare provider is caring for a child on bed rest who has severe edema in the left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority?

Correct answer: A

Rationale: The priority nursing diagnosis in this scenario is 'Risk for Impaired Skin Integrity' because severe edema in the left lower extremity can lead to compromised circulation and pressure ulcers, increasing the risk of skin breakdown and infection. Addressing and preventing impaired skin integrity is crucial for the child's overall health and well-being.

3. A client with heart failure has gained 2 kg (4.4 lbs) in the past 24 hours. What action should the nurse take first?

Correct answer: B

Rationale: Assessing the client's respiratory status is the priority as it helps determine if the weight gain is due to fluid retention affecting breathing. This assessment is crucial in addressing the immediate concern of potential respiratory distress before implementing interventions like fluid restriction, diuretics, or notifying the healthcare provider.

4. A healthcare professional is educating clients in an outpatient facility about the use of Insulin to treat type 1 Diabetes Mellitus. For which of the following types of insulin should the professional inform the clients to expect a peak effect 1 to 5 hr after administration?

Correct answer: C

Rationale: The correct answer is C, Regular insulin. Regular insulin, also known as short-acting insulin, typically exhibits a peak effect around 1 to 5 hours following administration. This rapid onset and peak effect make it suitable for managing postprandial glucose levels. Insulin glargine is a long-acting insulin with no pronounced peak effect, making it unsuitable for rapid glucose control within 1 to 5 hours. NPH insulin has an intermediate duration of action and a different peak time frame. Insulin lispro is a rapid-acting insulin that peaks within 30 minutes to 2.5 hours after administration, not within the 1 to 5-hour range.

5. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Correct answer: B

Rationale: The correct statement the nurse should make is that dehydration can increase the risk of preterm labor. Dehydration reduces amniotic fluid and uterine blood flow, potentially leading to preterm contractions. Choice A is incorrect because dehydration is not treated with calcium supplements but rather with adequate fluid intake. Choice C is incorrect as dehydration does not directly increase gastroesophageal reflux. Choice D is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by insufficient fluid intake or excessive fluid loss.

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