how should a nurse assess a patient for fluid overload

ATI LPN

ATI NCLEX PN Predictor Test

1. How should a healthcare provider assess a patient for fluid overload?

A. Monitor weight and assess for shortness of breath
B. Auscultate lung sounds and monitor blood pressure
C. Assess for edema in the extremities
D. Assess for jugular venous distension

Correct answer: A

Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.

2. What is the correct way to assess for pitting edema?

A. Press over the bony area for 5 seconds and release
B. Press over the skin for 10 seconds and check for discoloration
C. Press the area and check for the presence of rash
D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

3. How should a healthcare provider respond to a patient with a suspected pulmonary embolism?

A. Administer oxygen and call for emergency assistance
B. Position the patient in a prone position and give fluids
C. Administer anticoagulants and elevate the patient's legs
D. Administer thrombolytics and perform chest physiotherapy

Correct answer: A

Rationale: Administering oxygen and calling for emergency assistance are the immediate priorities when managing a suspected pulmonary embolism. Oxygen helps support the patient's respiratory function, while emergency assistance is crucial for further evaluation and treatment. Positioning the patient in a prone position or giving fluids can worsen the condition by impeding blood flow. Administering anticoagulants may be part of the treatment plan but is not the initial response. Thrombolytics and chest physiotherapy are not first-line treatments for suspected pulmonary embolism and can even be harmful without prior evaluation.

4. A nurse is collecting data from a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

A. I am frustrated that I cannot lift my arm to comb my hair.
B. I am upset that I can't hold a pencil anymore.
C. I am embarrassed that I cannot open my milk carton.
D. I am so frustrated that I cannot even open my milk carton for breakfast.

Correct answer: D

Rationale: The correct answer is D because the inability to perform activities of daily living, such as opening a milk carton, suggests difficulties with fine motor skills. Occupational therapists specialize in helping individuals regain independence in such tasks. Choices A, B, and C do not specifically address fine motor skills related to activities of daily living, therefore not warranting an occupational therapy referral. Choice A mentions lifting the arm, which involves gross motor skills rather than fine motor skills. Choice B involves holding a pencil, which is more related to hand dexterity and strength rather than fine motor skills. Choice C, opening a milk carton, could be related to fine motor skills but is not as clear-cut as the inability described in Choice D, where the frustration is explicitly about the inability to perform a daily living task.

5. A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?

A. Clamp the chest tube
B. Maintain the drainage below the level of the chest
C. Elevate the chest tube above chest level
D. Avoid frequent dressing changes

Correct answer: B

Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.