how does a nurse assess a patients fluid balance and what signs indicate fluid overload how does a nurse assess a patients fluid balance and what signs indicate fluid overload
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. How does a healthcare professional assess a patient's fluid balance, and what signs indicate fluid overload?

Correct answer: C

Rationale: The correct answer is monitoring intake and output and checking for edema. Monitoring intake and output provides information about fluid balance in the body, while checking for edema helps assess for fluid overload. Lung sounds and signs of orthopnea are more indicative of respiratory issues rather than fluid balance. Daily weight measurement is useful to assess fluid status, but it alone may not provide a comprehensive evaluation of fluid balance.

2. A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.

3. A multivitamin supplement containing folic acid is recommended for all young women because of the number of unintentional pregnancies in women 15 to 24 years old.

Correct answer: A

Rationale: Both the statement and the reason are correct and related. A multivitamin with folic acid is recommended for young women due to the high incidence of unplanned pregnancies in this age group.

4. Select all that apply. A person who is deficient in vitamin A could consume which of the following to increase vitamin A levels?

Correct answer: D

Rationale: Vitamin A can be found in high amounts in foods like cantaloupe, eggs, carrots, and milk, all of which help to maintain healthy vision, skin, and immune function.

5. A nurse is teaching a parent about appropriate snack choices for her 9-month-old infant. Which of the following food choices should the nurse recommend?

Correct answer: C

Rationale: Graham crackers are an appropriate snack choice for a 9-month-old infant due to their texture and ease of consumption. Skim milk (Choice A) is not recommended for infants under 1 year old due to the potential risk of developing milk allergies. Unsalted popcorn (Choice B) can be a choking hazard for infants. Raw carrots (Choice D) are a potential choking hazard for a 9-month-old infant and may be difficult for them to chew and digest.

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