a client is at risk for excess fluid volume which nursing intervention ensures the most accurate monitoring of the clients fluid status
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

Correct answer: B

Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.

2. Which of the following is NOT one of the three basic areas of concern into which practical nurse management responsibilities can be categorized?

Correct answer: A

Rationale: Managing patients' legal affairs is not a basic area of concern in practical nurse management responsibilities. The primary areas typically include managing work center operations, managing personnel, and overseeing patient care. Choice B, managing the hypothalamus, is irrelevant to nurse management responsibilities and is not a standard area of concern in this context. Choice C, managing work center operations, and Choice D, managing personnel, align more closely with the core responsibilities and concerns of practical nurse management roles.

3. Which of the following nursing interventions is important for a client scheduled to have a Guaiac Test?

Correct answer: A

Rationale: The correct answer is A. Turnips, radish, and horseradish are known to cause false-positive results in a Guaiac Test, which is used to detect blood in the stool. Avoiding these foods is crucial to ensure accurate test results. Choice B is incorrect as iron preparation is not directly related to the Guaiac Test. Choice C is incorrect because avoiding meat is not specifically necessary before a Guaiac Test. Choice D is incorrect as caffeine and dark-colored foods can potentially interfere with test results, so they should not be encouraged.

4. What type of food should a patient taking anticoagulants be cautious about consuming?

Correct answer: C

Rationale: Patients taking anticoagulants should be cautious about consuming high-vitamin K foods. Vitamin K can interfere with the effectiveness of anticoagulants by affecting blood clotting. Choices A, B, and D are incorrect because they do not directly interact with the action of anticoagulants.

5. In patients with heart failure, which type of diet is most recommended?

Correct answer: B

Rationale: In patients with heart failure, a low-sodium diet is most recommended. This type of diet helps manage fluid retention by reducing the amount of sodium in the body. Excess sodium can lead to fluid accumulation, putting additional strain on the heart. High-sodium diets can exacerbate symptoms of heart failure by causing fluid retention and increasing blood pressure. High-fat and low-carbohydrate diets are not specifically recommended for heart failure patients and may not address the underlying issues related to fluid balance and heart function.

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