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. Which of the following is an early indicator that suctioning is needed for a client with a tracheostomy?

A. Bradycardia
B. Hypotension
C. Irritability
D. Confusion

Correct answer: C

Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.

3. What are the key signs of hyperkalemia and how should it be treated?

A. Elevated potassium levels, muscle weakness; administer calcium gluconate
B. Decreased potassium levels, confusion; administer potassium chloride
C. Elevated sodium levels, bradycardia; administer sodium bicarbonate
D. Low sodium levels, muscle cramps; administer sodium chloride

Correct answer: A

Rationale: The correct signs of hyperkalemia include elevated potassium levels and muscle weakness. The treatment involves administering calcium gluconate to help stabilize the heart. Choice B is incorrect as hyperkalemia is characterized by elevated, not decreased, potassium levels. Choice C is incorrect as hyperkalemia does not involve elevated sodium levels, and the treatment is not sodium bicarbonate. Choice D is incorrect as hyperkalemia does not lead to low sodium levels, and sodium chloride is not the treatment for hyperkalemia.

4. What are the steps in providing perineal care to a patient?

A. Clean the perineal area with soap and water
B. Use antiseptic wipes to prevent infection
C. Pat the area dry after cleaning
D. Always use gloves when performing care

Correct answer: A

Rationale: The correct answer is A: Clean the perineal area with soap and water. This step is essential in preventing infection and promoting hygiene. Using antiseptic wipes (choice B) is not a standard practice for perineal care; soap and water are preferred. While patting the area dry after cleaning (choice C) is important, the initial step of cleaning with soap and water is crucial. Using gloves (choice D) is a good practice to prevent the spread of infection, but it is not the initial step in providing perineal care.

5. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent atelectasis?

A. Encourage deep breathing exercises
B. Encourage the client to cough every 2 hours
C. Administer an incentive spirometer
D. Assist the client to ambulate in the hallway

Correct answer: C

Rationale: The correct answer is C: Administer an incentive spirometer. Using an incentive spirometer helps prevent atelectasis by encouraging lung expansion after surgery. Encouraging deep breathing exercises (choice A) is beneficial but may not be as effective as an incentive spirometer. Encouraging the client to cough (choice B) helps with airway clearance but does not directly prevent atelectasis. Assisting the client to ambulate (choice D) is important for preventing complications such as deep vein thrombosis, but it is not the most effective intervention for preventing atelectasis.