how should a nurse manage a patient with fluid overload
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Nursing Elites

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

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 collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Correct answer: C

Rationale: The correct answer is C: 'Lack of sleep.' In a client experiencing acute mania due to bipolar disorder, lack of sleep is the priority finding for the nurse to address. Sleep deprivation can exacerbate symptoms, lead to exhaustion, and increase the risk of further complications. Pressured speech, increased appetite, and mood swings are also common in acute mania, but addressing the lack of sleep takes precedence due to its significant impact on the client's well-being and recovery.

3. Which of the following is an early indication that a tracheostomy client requires suctioning?

Correct answer: B

Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.

4. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?

Correct answer: B

Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.

5. What are the nursing interventions for a patient receiving anticoagulant therapy?

Correct answer: A

Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.

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