MS ATI Assessment 100% VERIFIED SOLUTION 2023/2024

MS ATI Assessment 100% VERIFIED SOLUTION 2023/2024 A nurse is reinforcing discharge teaching with a client who recently diagnosed with heart failure. Which of the following statements should the nurse include in the teaching? A) "Begin exercising twice per week." B) "Consume a low-residue diet." C) "Weigh yourself every 2 days." D) "Limit sodium intake to 3.5 g daily." ANS: A) "Begin exercising twice per week." RATIONALE: The nurse should reinforce to the client to begin walking twice a week, then gradually build tolerance to increase walking to at least three times weekly, increasing distance as the client is able. A nurse on a telemetry unit is reviewing laboratory results for a client who has atrial fibrillation and is taking warfarin. Which of the following laboratory values should the nurse report to the provider? A) PT 45 seconds B) Hgb 16 g/dL C) aPTT 36 seconds D) Platelets 190,000/mm3 ANS: A) PT 45 seconds RATIONALE: The expected reference range for PT is 11 to 12.5 seconds. During therapy, the nurse should expect to see the values increase 1.5 to 2.5 times the baseline. Therefore, the nurse should withhold the warfarin and notify the provider. A nurse is planning to perform an electrocardiogram (ECG) for a client who has a history of coronary heart disease. Which of the following actions should the nurse take? (Select all that apply.) A) Keep the client NPO after midnight. B) Inspect the electrode pads. C) Use alcohol to wipe the skin before placing the electrodes. D) Instruct the client to breath normally. E) Administer an analgesic prior to the procedure. ANS: B, C, D RATIONALE: Inspect the electrode pads is correct. The nurse should inspect the electrode pads to check that the gel is present because the gel is necessary to promote electrical conduction between the skin and the electrodes. Use alcohol to wipe the skin before placing the electrodes is correct. The nurse should wipe the skin where she will place the electrodes to ensure the skin is free of oils and other matter. Instruct the client not to talk is correct. The nurse should instruct the client to lie quietly, not talk, or move to prevent the recording of artifact. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? A) Productive cough B) Hepatomegaly C) Dizziness D) Crackles ANS: B) Hepatomegaly RATIONALE: Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure. This occurs as a result of the inability of the right side of the heart to work effectively as a pump. The systemic blood flow accumulates in the liver and spleen, resulting in hepatomegaly and splenomegaly. A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily for heart failure. The client's current vital signs are: BP 144/96, heart rate 54/min, respiration 18/min, and temperature 37 degrees C (98.6 degree F). Which of the following actions should the nurse take? A) Administer digoxin 0.125 mg. B) Administer digoxin 0.25 mg. C) Withhold the digoxin dose for elevated BP. D) Withhold the digoxin dose for decreased heart rate