a nurse is caring for a client with heart failure who has gained 2 kg 44 lbs in the past 24 hours what action should the nurse take first a nurse is caring for a client with heart failure who has gained 2 kg 44 lbs in the past 24 hours what action should the nurse take first
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. 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.

2. A healthcare professional is reviewing a client's admission laboratory results. Which of the following findings requires further evaluation?

Correct answer: B

Rationale: The correct answer is B. An elevated creatinine level, such as 1.8, suggests potential kidney dysfunction, requiring further assessment. Sodium level within normal limits (135-145 mEq/L), hemoglobin level of 15 g/dL, and potassium level of 4.2 mEq/L are all within normal ranges and do not indicate immediate concerns. Therefore, they do not require further evaluation at this time.

3. Which of the following is the correct method to reduce the risk of infection when handling a urinary catheter?

Correct answer: B

Rationale: The correct method to reduce the risk of infection when handling a urinary catheter is to maintain sterile technique when inserting the catheter. Sterile technique helps prevent introducing pathogens into the urinary system, reducing the risk of infection. Choice A is incorrect because cleaning the catheter tubing with soap and water is not sufficient for preventing infection. Choice C is incorrect as clean gloves and technique are not enough; sterile technique is necessary. Choice D is incorrect as flushing the catheter tubing with sterile water, though important for maintaining catheter patency, does not address the need for sterile technique during insertion to prevent infection.

4. What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age?

Correct answer: A

Rationale: Large push-pull toys are suitable for a 12-month-old as they encourage gross motor skills and physical activity, which are crucial for their development at this age.

5. The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?

Correct answer: C

Rationale: Time-outs should be in a safe, nonstimulating area, with the length typically being 1 minute per year of the child's age, not 1 hour.

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