what are the early signs of heart failure in a patient

ATI LPN

ATI PN Comprehensive Predictor 2024

1. What are the early signs of heart failure in a patient?

A. Shortness of breath and weight gain
B. Fatigue and chest pain
C. Nausea and vomiting
D. Cough and elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. Early signs of heart failure typically manifest as shortness of breath due to fluid accumulation in the lungs and weight gain due to fluid retention in the body. Choices B, C, and D are incorrect. Fatigue and chest pain are symptoms commonly associated with heart conditions but are not specific early signs of heart failure. Nausea and vomiting are not typically early signs of heart failure. Cough can be a symptom of heart failure, but it is usually associated with other symptoms like shortness of breath rather than being an isolated early sign. Elevated blood pressure is not an early sign of heart failure; in fact, heart failure is more commonly associated with low blood pressure.

2. A client with active tuberculosis is receiving discharge instructions. Which statement by the client indicates an understanding of the teaching?

A. I will continue taking my isoniazid until I am no longer contagious.
B. I should take my prescribed medication for at least 6 months.
C. I will need to have a TB skin test every 3 months.
D. I should wear a mask at all times.

Correct answer: B

Rationale: The correct answer is B because the client should take antitubercular medications for a minimum of 6 months to ensure complete eradication of the infection. Choice A is incorrect as stopping the medication early can result in treatment failure and development of drug-resistant TB. Choice C is incorrect as regular TB skin tests are not needed once the client has been diagnosed and treated. Choice D is incorrect as wearing a mask at all times is not necessary for a client with active TB; proper cough etiquette should be followed instead.

3. What is the proper technique for measuring a patient's blood pressure?

A. Place the cuff at heart level and listen for Korotkoff sounds
B. Ensure the patient is in a seated position and inflate the cuff to 180 mmHg
C. Use a manual sphygmomanometer and measure blood pressure on both arms
D. Monitor pulse rate and apply pressure to the brachial artery

Correct answer: A

Rationale: The correct technique for measuring blood pressure involves placing the cuff at heart level to ensure accurate readings. Listening for Korotkoff sounds helps determine the systolic and diastolic pressures. Choice B is incorrect as inflating the cuff to 180 mmHg is excessive and can lead to inaccurate readings. Choice C is incorrect as it is unnecessary to measure blood pressure on both arms unless there is a specific medical reason to do so. Choice D is incorrect as monitoring pulse rate and applying pressure to the brachial artery are not part of the standard blood pressure measurement technique.

4. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?

A. Elevate the IV site and apply an ice pack
B. Administer an anti-inflammatory medication
C. Apply a cold compress to the IV site
D. Discontinue the IV and notify the provider

Correct answer: D

Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.

5. A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

A. Monitor daily fluid intake
B. Monitor blood glucose levels
C. Measure intake and output
D. Administer insulin as prescribed

Correct answer: B

Rationale: The correct answer is B: 'Monitor blood glucose levels.' When a client is receiving total parenteral nutrition (TPN), which has a high glucose content, it is crucial to monitor blood glucose levels closely to prevent hyperglycemia. Monitoring daily fluid intake (Choice A) is important in other contexts but is not directly related to TPN administration. Measuring intake and output (Choice C) is a general nursing intervention that is relevant for assessing fluid balance but is not specific to TPN administration. Administering insulin as prescribed (Choice D) may be necessary for clients with hyperglycemia, but this intervention is based on the blood glucose monitoring results and the healthcare provider's orders, not a standard intervention for all clients receiving TPN.