a nurse is assessing a client who has chronic heart failure which of the following findings indicates that the client is experiencing fluid overload
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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. How should a healthcare professional manage a patient with fluid overload in heart failure?

Correct answer: A

Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.

3. A client with a new diagnosis of Graves' disease and a prescription for propylthiouracil (PTU) is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because propylthiouracil (PTU) can increase the risk of infection. Therefore, the client should be aware that this medication may compromise their immune system, making them more susceptible to infections. Reporting any signs of infection promptly to the provider is crucial for timely intervention and management. Choices A, B, and D are incorrect because reporting a sore throat, assuming lifelong medication intake, or experiencing decreased appetite are not directly related to the medication's side effects or risks.

4. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Pallor. Pallor, which is paleness of the skin, is a common sign of anemia due to a decreased number of red blood cells or hemoglobin levels. This results in reduced oxygen-carrying capacity, leading to the paleness of the skin. Choice A, increased appetite, is not typically associated with anemia. Choice C, tachycardia (increased heart rate), can be present in anemia as the body compensates for decreased oxygenation. Choice D, hypertension (high blood pressure), is not a common finding in anemia; instead, low blood pressure may be observed due to decreased blood volume.

5. A nurse is teaching a client about the physiological changes that occur with aging. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: The correct answer is A: Decreased sense of taste. As individuals age, they may experience a decrease in their sense of taste due to changes in taste buds and a decrease in saliva production. This can lead to a reduced ability to taste flavors or distinguish between different tastes. Choices B, C, and D are incorrect. Decreased blood pressure is not a consistent physiological change with aging; instead, blood pressure may increase or remain stable. Gastric secretions tend to decrease with age, leading to issues like decreased absorption of certain nutrients. Accommodation to near vision typically decreases with age, causing a condition known as presbyopia, where individuals have difficulty focusing on close objects.

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