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 first step in managing a patient with a suspected pneumothorax?

A. Insert a chest tube
B. Monitor respiratory status
C. Administer oxygen
D. Call for assistance

Correct answer: A

Rationale: The correct answer is to insert a chest tube. In managing a patient with a suspected pneumothorax, the priority is to relieve the pressure from the pneumothorax by inserting a chest tube. Monitoring respiratory status (choice B) is important but comes after ensuring proper management of the pneumothorax. Administering oxygen (choice C) can help support oxygenation but does not address the underlying issue of pressure in the thoracic cavity. Calling for assistance (choice D) can be done concurrently with managing the pneumothorax, but the immediate intervention to address the pneumothorax itself is chest tube insertion.

3. A nurse is caring for a client who is constipated. What intervention is most appropriate?

A. Administer a laxative to relieve discomfort
B. Encourage the client to increase dietary fiber intake
C. Encourage the client to rest until symptoms resolve
D. Administer a stool softener as prescribed

Correct answer: B

Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.

4. A home health nurse is caring for an older adult client who just returned home following a total knee arthroplasty. Which of the following actions should the nurse take first?

A. Assess mobility
B. Monitor vital signs
C. Provide pain relief
D. Reinforce discharge teaching

Correct answer: A

Rationale: Assessing mobility should be the nurse's priority as it ensures the client's safety and helps in developing an appropriate care plan. By evaluating the client's ability to move after the knee arthroplasty, the nurse can identify any immediate issues or complications that need to be addressed promptly. Monitoring vital signs, providing pain relief, and reinforcing discharge teaching are important aspects of care but assessing mobility takes precedence in ensuring the client's immediate well-being and identifying any potential risks.

5. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?

A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL

Correct answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.