which intervention should be included for a client with heart failure
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023

1. Which intervention should be included for a client with heart failure?

Correct answer: B

Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.

2. What is the most effective way to prevent the spread of infection in a healthcare setting?

Correct answer: A

Rationale: Hand hygiene is considered the most effective method to prevent the spread of infection in a healthcare setting. Proper hand hygiene, including washing hands with soap and water or using hand sanitizer, is crucial in reducing the transmission of pathogens from one person to another. While wearing personal protective equipment, sterilizing equipment, and isolating infected patients are also important infection control measures, they are not as universally effective as hand hygiene in preventing the spread of infections. Personal protective equipment can prevent contact with infectious materials, sterilizing equipment reduces the risk of contamination, and isolating infected patients helps prevent the spread of specific infections, but they are more targeted approaches compared to the broad and essential practice of hand hygiene.

3. What is the nurse's role in preoperative patient care?

Correct answer: A

Rationale: The nurse plays a crucial role in preoperative patient care by providing education and ensuring NPO (nothing by mouth) status. This helps prepare the patient for surgery by ensuring they understand the procedure, what to expect, and also by following necessary preoperative fasting guidelines. While obtaining the patient's health history (choice C) is important for overall patient assessment, it is typically done during the preoperative assessment but does not specifically pertain to the nurse's role. Ensuring informed consent (choice B) is primarily the responsibility of the healthcare provider performing the procedure. Confirming the patient's surgical site (choice D) is usually the responsibility of the surgical team and is done immediately before the surgery to prevent errors.

4. A client who is at 36 weeks of gestation is being taught about nonstress testing. Which of the following statements should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C. In a nonstress test, the client is required to press a handheld button whenever fetal movement is felt, which is then recorded on the monitor. This action helps assess the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. Choices A, B, and D are incorrect because the nonstress test does not involve determining the length of the cervix, monitoring blood pressure, or being completed in 5 minutes. These aspects are not part of the nonstress testing procedure and are unrelated to the purpose of the test.

5. A nurse is reinforcing teaching about ways to reduce solid fat consumption with a client who has an elevated cholesterol level. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Choose lean cuts of beef.' Selecting lean cuts of beef is crucial in reducing solid fat consumption for individuals with high cholesterol levels. Lean cuts contain less saturated fat compared to fatty cuts, thus aiding in managing cholesterol levels. Option A is incorrect as oils with trans fats should be avoided since they contribute to unhealthy fats. Option C is not directly related to reducing solid fat consumption. Option D, while suggesting a leaner meat option, does not address the issue of solid fat consumption as directly as choosing lean cuts of beef.

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