a nurse is teaching a client who has heart failure about fluid restrictions which of the following instructions should the nurse include

ATI LPN

PN ATI Comprehensive Predictor

1. A nurse is teaching a client who has heart failure about fluid restrictions. Which of the following instructions should the nurse include?

A. Limit fluid intake to 3 liters per day
B. Limit fluid intake to 1-2 liters per day
C. Drink 4 liters of water per day
D. Restrict water intake to 1 liter per day

Correct answer: B

Rationale: The correct answer is B: 'Limit fluid intake to 1-2 liters per day.' For clients with heart failure, fluid restriction is essential to prevent fluid overload. Restricting fluid intake to 1-2 liters per day helps maintain fluid balance and prevents exacerbation of heart failure symptoms. Choices A, C, and D are incorrect because consuming 3 liters, 4 liters, or limiting water intake to 1 liter per day, respectively, can lead to fluid overload in clients with heart failure.

2. A client who is to undergo an exercise stress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

A. I should eat a large meal 2 hours before the test
B. I should avoid drinking water before the test
C. I should stop taking my blood pressure medication
D. I should report any chest pain during the test

Correct answer: D

Rationale: The correct answer is D: 'I should report any chest pain during the test.' This statement indicates an understanding of the teaching because reporting chest pain during an exercise stress test is crucial as it may signify cardiac distress. Choices A, B, and C are incorrect. Eating a large meal 2 hours before the test is not recommended as it may affect the results. Avoiding drinking water before the test is also not advisable as staying hydrated is important. Stopping blood pressure medication without medical advice can be dangerous, especially before a stress test.

3. How should a healthcare professional manage a patient with suspected myocardial infarction (MI)?

A. Administer oxygen and call for emergency help
B. Monitor vital signs and provide pain relief
C. Provide nitroglycerin and thrombolytics
D. Administer diuretics and provide a high-protein diet

Correct answer: A

Rationale: Administering oxygen and seeking emergency help are crucial initial steps in managing a patient with suspected myocardial infarction (MI). Oxygen helps to improve oxygenation to the heart muscle, reducing its workload and preventing further damage. Calling for emergency help ensures timely access to advanced medical care, including interventions like thrombolytics. Monitoring vital signs and providing pain relief are important but secondary to the immediate need for oxygen and emergency assistance. Providing nitroglycerin and thrombolytics should be done under medical supervision and following appropriate protocols, not as the first step. Administering diuretics and altering the patient's diet are not indicated in the acute management of MI.

4. What are the nursing interventions for a patient with a pressure ulcer?

A. Clean the wound and apply a hydrocolloid dressing
B. Provide a high-protein diet and ensure bed rest
C. Monitor for signs of infection and provide antibiotics
D. Provide a low-sodium diet and monitor for fluid retention

Correct answer: A

Rationale: The correct nursing intervention for a patient with a pressure ulcer is to clean the wound and apply a hydrocolloid dressing. This promotes healing by creating a moist environment conducive to the wound healing process. Choice B is incorrect because while nutrition is important for wound healing, a high-protein diet alone is not a specific intervention for a pressure ulcer. Choice C is incorrect as antibiotics are only used if there is an infection present. Choice D is also incorrect as a low-sodium diet and monitoring for fluid retention are more related to conditions like heart failure or kidney disease, not specifically pressure ulcer care.

5. What are key signs of a urinary tract infection (UTI) in older adults?

A. Confusion and increased temperature
B. Painful urination and frequent urination
C. Dizziness and headache
D. Back pain and fever

Correct answer: A

Rationale: The correct answer is A. In older adults, key signs of a UTI often include confusion and increased temperature. Confusion is a common symptom in the elderly when they have a UTI, and an increase in body temperature can indicate an infection. Choices B, C, and D are incorrect because while painful urination and frequent urination are common UTI symptoms in general, they may not be as prominent in older adults. Dizziness, headache, back pain, and fever can be associated with other conditions but are not typically key signs of a UTI in older adults.