a nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg po twice daily which of the followin

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A client with heart failure is prescribed furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include during discharge teaching?

A. Monitor for increased blood pressure
B. Increase intake of high-potassium foods
C. Expect an increase in swelling in the hands and feet
D. Take the second dose at bedtime

Correct answer: B

Rationale: The correct answer is to instruct the client to increase their intake of high-potassium foods. Furosemide can lead to hypokalemia, a condition of low potassium levels in the blood. Increasing the consumption of high-potassium foods helps prevent this adverse effect. Monitoring for increased blood pressure (choice A) is not directly related to furosemide use. Expecting an increase in swelling (choice C) is incorrect as furosemide is a diuretic that helps reduce swelling. Taking the second dose at bedtime (choice D) is not necessary unless prescribed by the healthcare provider.

2. What dietary recommendations should be given to a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bed
C. Increase fluid intake during meals
D. Drink milk as a snack

Correct answer: A

Rationale: The correct dietary recommendation for a patient with GERD is to avoid mint and spicy foods. These foods can trigger symptoms of GERD and lead to acid reflux. Choice B is incorrect because eating large meals before bed can exacerbate GERD symptoms by increasing the likelihood of acid reflux during sleep. Choice C is incorrect as increasing fluid intake during meals can worsen GERD symptoms by distending the stomach, leading to increased pressure on the lower esophageal sphincter. Choice D is also incorrect because while milk may provide temporary relief for some individuals, it is not a recommended long-term solution for managing GERD.

3. What intervention is needed for a patient with a chest tube and an air leak?

A. Tighten the connections of the chest tube system
B. Replace the chest tube
C. Clamp the chest tube
D. Continue to monitor the chest tube

Correct answer: A

Rationale: The correct intervention for a patient with a chest tube and an air leak is to tighten the connections of the chest tube system. This step helps prevent air leaks and ensures the proper functioning of the chest tube. Choice B, replacing the chest tube, is not necessary as tightening the connections should be attempted first. Clamping the chest tube (Choice C) is not recommended as it can lead to complications by obstructing the drainage system. Continuing to monitor the chest tube (Choice D) without taking action may result in worsening of the air leak. Therefore, the priority intervention is to tighten the connections of the chest tube system.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

A. Decreased deep tendon reflexes
B. Positive Chvostek's sign
C. Hyperactive bowel sounds
D. Dry mucous membranes

Correct answer: A

Rationale: Corrected deep tendon reflexes occur with hyponatremia. Other manifestations of hyponatremia include headache, confusion, lethargy, fatigue, seizures, and muscle weakness. Positive Chvostek's sign is associated with hypocalcemia, hyperactive bowel sounds are not typically related to hyponatremia, and dry mucous membranes are more commonly seen with dehydration.

5. A patient who received an enema reports abdominal cramping. What should the nurse do?

A. Increase the flow of the enema solution
B. Lower the height of the enema solution container
C. Remove the enema tubing
D. Stop the procedure

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.