A client with a history of renal failure is being cared for by a nurse. Which of the following should the nurse monitor?

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PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN Questions

Question 1 of 4

A client with a history of renal failure is being cared for by a nurse. Which of the following should the nurse monitor?

Correct Answer: D

Rationale: Clients with renal failure are at risk for electrolyte imbalances and hypertension. Monitoring electrolyte levels is crucial because renal failure can lead to imbalances in sodium, potassium, and other electrolytes. Blood pressure monitoring is essential as hypertension is a common complication of renal failure. Therefore, both electrolyte levels and blood pressure should be closely monitored to detect and manage any abnormalities. Fluid intake, while important, is not specific to renal failure monitoring and is not the priority in this case.

Question 2 of 4

A nurse is assessing a client with a history of heart failure. Which of the following findings should the nurse monitor?

Correct Answer: B

Rationale: The correct answer is B: Peripheral edema. In heart failure, the heart's inability to pump effectively can lead to fluid backup, causing swelling in the extremities, known as peripheral edema. Monitoring for peripheral edema is crucial as it is a common sign of worsening heart failure. Choices A, C, and D are incorrect because increased energy, elevated heart rate, and improved lung sounds are not typical findings in heart failure. Increased energy is not usually associated with heart failure, an elevated heart rate may occur as a compensatory mechanism but is not a direct sign of heart failure, and improved lung sounds are not expected in heart failure which often presents with crackles or wheezes due to pulmonary congestion.

Question 3 of 4

A nurse is preparing to administer a dose of escitalopram. Which of the following should the nurse assess first?

Correct Answer: A

Rationale: The correct answer is to assess for mood changes. When administering escitalopram, it is crucial to evaluate mood changes first because the medication may take some time to demonstrate its full effects on the patient's mood. Assessing blood pressure, heart rate, or liver function is not the priority when administering escitalopram, as these parameters are not directly impacted acutely by this medication.

Question 4 of 4

A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?

Correct Answer: A

Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.

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