how should a nurse manage a patient with fluid overload

ATI LPN

PN ATI Comprehensive Predictor

1. How should a healthcare professional manage a patient with fluid overload?

A. Restrict fluids and administer diuretics
B. Increase fluid intake and provide oral diuretics
C. Administer antibiotics and monitor weight
D. Monitor weight and provide a low-sodium diet

Correct answer: A

Rationale: Corrected Question: When managing a patient with fluid overload, the appropriate approach involves restricting fluids and administering diuretics. This strategy helps remove excess fluid from the body and prevent complications associated with fluid overload. Choice B suggesting increasing fluid intake is incorrect as it would worsen the condition. Choice C, administering antibiotics, is unrelated to managing fluid overload. Choice D, monitoring weight and providing a low-sodium diet, is helpful but not as effective as fluid restriction and diuretics in managing fluid overload.

2. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A. A client with pneumonia who had new onset of confusion
B. A client with diabetes who had low blood sugar overnight
C. A client with a leg fracture who needs pain medication
D. A client whose urinary output was 100 mL for the past 12 hours

Correct answer: A

Rationale: The correct answer is A. New confusion in a client with pneumonia could indicate hypoxia or a worsening condition, requiring immediate attention. Option B, a client with diabetes having low blood sugar overnight, is a concerning condition but not as urgent as potential hypoxia. Option C, a client with a leg fracture needing pain medication, and option D, a client with decreased urinary output, are important but do not take precedence over addressing a potentially critical respiratory issue.

3. What are the key differences between systolic and diastolic heart failure?

A. Systolic: Reduced ejection fraction; Diastolic: Preserved ejection fraction
B. Systolic: Preserved ejection fraction; Diastolic: Reduced ejection fraction
C. Systolic: Right-sided heart failure; Diastolic: Left-sided heart failure
D. Systolic: Pulmonary congestion; Diastolic: Systemic congestion

Correct answer: A

Rationale: The correct answer is A. Systolic heart failure is characterized by reduced ejection fraction, meaning the heart is not pumping effectively. Diastolic heart failure, on the other hand, is characterized by preserved ejection fraction, indicating that the heart has difficulty relaxing and filling properly. Choices B, C, and D are incorrect because they do not accurately describe the key differences between systolic and diastolic heart failure.

4. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?

A. Can you tell me who visited you today?
B. What high school did you graduate from?
C. Can you list your current medications?
D. What did you have for breakfast yesterday?

Correct answer: B

Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.

5. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

A. Ignore the behavior
B. Reassign the AP
C. Report the behavior to the manager
D. Discuss this behavior with the AP while reinforcing expectations

Correct answer: D

Rationale: When a charge nurse observes repeated failure in a staff member's performance, it is essential to address the issue directly. Choice D is the correct answer as it involves discussing the behavior with the assistive personnel (AP) while reinforcing expectations. This approach helps in clarifying the expected standards, setting accountability, and providing an opportunity for improvement. Choices A, B, and C are incorrect. Ignoring the behavior (Choice A) does not address the problem and can lead to continued substandard care. Reassigning the AP (Choice B) may not solve the issue and can potentially transfer the problem to another area. Reporting the behavior to the manager (Choice C) without directly addressing it with the AP first may not promote a constructive approach to resolving the issue.