how should a nurse assess a patient for fluid overload
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

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

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. Which dietary advice should a healthcare provider provide to a client with acute gout?

Correct answer: B

Rationale: The correct dietary advice for a client with acute gout is to limit the intake of red meat and shellfish. These foods are high in purines, which can lead to increased uric acid levels in the body, exacerbating gout symptoms. Dairy products, fresh fruits, and vegetables are generally recommended for individuals with gout as they can help lower uric acid levels. Fruit juices and milk, in moderation, can also be part of a gout-friendly diet as they do not significantly contribute to uric acid buildup.

3. What is the initial step a nurse should take when irrigating a wound?

Correct answer: B

Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.

4. The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?

Correct answer: B

Rationale: Maintaining optimal function within the client's limitations is the most realistic and appropriate nursing goal when caring for an 80-year-old client with Parkinson's disease. This goal focuses on maximizing the client's abilities and quality of life while acknowledging the impact of the disease. Option A is less realistic as returning to usual activities may not always be achievable in the case of Parkinson's disease. Option C is not appropriate as it does not address the client's current condition and care needs. Option D is less realistic as Parkinson's disease is progressive, and delaying its progression may not be entirely feasible.

5. What is the most important nursing action when administering IV potassium?

Correct answer: C

Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.

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