a nurse is assessing a patients fluid balance what is the most reliable indicator of fluid status
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

2. A patient is being taught to use TD nitroglycerin patches to treat angina pectoris. What instructions should be included?

Correct answer: B

Rationale: The correct answer is to apply a new patch every morning. Nitroglycerin patches should be applied in the morning and removed at bedtime to provide a 14-hour nitrate-free interval, preventing tolerance development. Choice A is incorrect because applying a patch every 12 hours may lead to tolerance. Choice C is incorrect because nitroglycerin patches are used prophylactically, not just when symptoms appear. Choice D is incorrect because rotating the application site weekly is not necessary; the same site can be used as long as there is no skin irritation.

3. A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?

Correct answer: C

Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.

4. A nurse is assessing the skin of an immobilized patient. What will the nurse do?

Correct answer: A

Rationale: The correct answer is A. When assessing the skin of an immobilized patient, it is essential to use a standardized tool such as the Braden Scale to identify patients at high risk for impaired skin integrity. This tool helps in early identification and appropriate intervention. Choice B, limiting fluid intake, is not directly related to skin assessment. Choice C, having special times for inspection, may not ensure timely identification of skin issues. Choice D, assessing the skin every 4 hours, lacks specificity regarding the use of a validated tool for risk assessment.

5. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.

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