a nurse is assessing a client who has chronic heart failure which of the following findings indicates that the client is experiencing fluid overload
Logo

Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. A nurse is assessing a client who has chronic heart failure. Which of the following findings indicates that the client is experiencing fluid overload?

Correct answer: B

Rationale: In clients with chronic heart failure, bounding peripheral pulses are a classic sign of fluid overload. This occurs due to increased volume in the arterial system, causing a forceful pulse. Increased urine output (Choice A) is often seen in clients with fluid volume deficit, not overload. Weight loss (Choice C) is also inconsistent with fluid overload as it suggests a fluid deficit. Decreased heart rate (Choice D) is more commonly associated with conditions like bradycardia, hypothyroidism, or the use of certain medications, but not specifically indicative of fluid overload in chronic heart failure.

2. A nurse is caring for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct intervention for a client with Alzheimer's disease who demonstrates confusion and wandering behavior is to ensure that the client wears an identification bracelet at all times. This helps prevent wandering and ensures the client's safety. Placing the client in a well-lit area may be beneficial for orientation but does not directly address wandering behavior. Using physical restraints is not recommended as it can lead to agitation and other complications. Keeping the client's bed in the lowest position is important for fall prevention but does not specifically address the issue of wandering behavior.

3. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.

4. A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?

Correct answer: D

Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.

5. A nurse is caring for a client who has acute pancreatitis. Which of the following laboratory findings should the nurse expect to be elevated?

Correct answer: C

Rationale: The correct answer is C: Amylase. Amylase levels are elevated in clients with acute pancreatitis due to inflammation of the pancreas. Elevated hemoglobin (choice A) is not typically associated with acute pancreatitis. Bilirubin (choice B) may be elevated in conditions affecting the liver, not specifically in acute pancreatitis. Creatinine (choice D) is a marker of kidney function and is not directly related to acute pancreatitis.

Similar Questions

A healthcare professional is caring for a client who has a prescription for enoxaparin. Which of the following laboratory tests should the healthcare professional review before administering the medication?
A healthcare professional is providing discharge teaching for a client with type 2 diabetes mellitus. Which resource should be provided?
A nurse is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the nurse report to the provider?
A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes mellitus. Which of the following client statements indicates a need for further teaching?
A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should the nurse include?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses