a patient with heart failure has gained 5 pounds in the last 3 days what is the nurses priority intervention a patient with heart failure has gained 5 pounds in the last 3 days what is the nurses priority intervention
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?

Correct answer: B

Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.

2. A client who is postoperative following a total hip arthroplasty is at risk for hip dislocation. Which of the following actions should the nurse take to prevent this complication?

Correct answer: C

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents the hip from dislocating. This position aids in keeping the hip in a neutral or slightly outwardly rotated position, reducing the risk of dislocation. Placing the client supine with a pillow between the legs (Choice A) or using a trochanter roll (Choice D) may not provide the same level of abduction and support needed to prevent hip dislocation. Placing a pillow under the client's knees (Choice B) does not provide the necessary support to maintain proper hip alignment in this situation.

3. A healthcare professional is teaching about implementing a heart-healthy diet to a client who has coronary artery disease. Which of the following foods should the professional recommend to the client?

Correct answer: C

Rationale: Broiled salmon is a heart-healthy food due to its high omega-3 fatty acid content, which helps reduce inflammation and improve cardiovascular health. Choices A, B, and D are not recommended for a heart-healthy diet. Baked ham and processed cheese are high in saturated fats and sodium, which can be detrimental to cardiovascular health. Canned potato soup may contain high levels of sodium and preservatives, making it less suitable for a heart-healthy diet.

4. Which statement by the parents indicates understanding of the process involved with a kidney transplant for a child with renal failure?

Correct answer: D

Rationale: The correct answer is D because parents should understand the importance of medication adherence post-transplant to prevent rejection. Following the prescribed medication regimen is crucial for the success of the kidney transplant and the overall health of the child. Monitoring and ensuring the child takes their medications as directed by the healthcare provider are essential components of post-transplant care. Choices A, B, and C are incorrect because they do not address the critical aspect of medication management post-transplant, which is vital for the child's well-being and the success of the procedure.

5. Which test measures the electrical activity of the heart and can detect arrhythmias and other heart conditions?

Correct answer: A

Rationale: The correct answer is A: Electrocardiogram (ECG or EKG). An electrocardiogram is a test that measures the electrical activity of the heart and can detect arrhythmias and other heart conditions by recording the heart's electrical impulses. Choices B, C, and D are incorrect because a chest X-ray is used to visualize the structures in the chest, an MRI (Magnetic Resonance Imaging) is used to provide detailed images of organs and tissues, and a CT scan (Computed Tomography) is a type of imaging that uses X-rays to create detailed cross-sectional images of the body.

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