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. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

Correct answer: A

Rationale: The correct answer is A: Deep tendon reflexes. When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Choices B, C, and D are not directly related to the assessment needed when administering magnesium sulfate in this scenario. Arterial blood gases are not typically assessed specifically for magnesium sulfate administration; skin turgor and capillary refill time are more related to hydration status and perfusion, respectively.

3. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?

Correct answer: D

Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

4. The type of lipoprotein that carries cholesterol from tissues to the liver for excretion is:

Correct answer: D

Rationale: The correct answer is D, High-density lipoprotein (HDL). HDL is known as the 'good' cholesterol and plays a crucial role in transporting cholesterol from tissues back to the liver for excretion. This process helps in reducing the buildup of cholesterol in the bloodstream, thus lowering the risk of heart diseases. Very low-density lipoprotein (Option A), Intermediate-density lipoprotein (Option B), and Low-density lipoprotein (Option C) are not responsible for carrying cholesterol back to the liver for excretion like HDL does. Instead, they are associated with different functions related to cholesterol transportation within the body.

5. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

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