how should a nurse manage fluid overload in a patient with heart failure
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. How should fluid overload in a patient with heart failure be managed?

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

2. A client with schizophrenia starting therapy with clozapine is being discharged. Which symptom should the client report to the provider as the highest priority?

Correct answer: C

Rationale: The correct answer is C: Fever. When a client is taking clozapine, fever can indicate serious conditions such as infection or severe reactions, which need immediate medical attention. Constipation (choice A), blurred vision (choice B), and dry mouth (choice D) are common side effects of clozapine but are not as urgent as fever. Constipation can be managed with dietary changes or medications, blurred vision can improve over time, and dry mouth can be relieved with frequent sips of water.

3. What is the priority nursing action for a patient with confusion post-surgery?

Correct answer: A

Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.

4. A client has a new prescription for alendronate. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction when taking alendronate is to remain upright for 30 minutes after administration. This helps prevent esophageal irritation, a known side effect of the medication. Option A is incorrect because alendronate should be taken in the morning on an empty stomach. Option B is incorrect as taking alendronate with food decreases its absorption. Option D is incorrect as alendronate should be swallowed whole with a full glass of water and not chewed.

5. How should a healthcare professional monitor a patient for infection post-surgery?

Correct answer: A

Rationale: Monitoring the surgical site is crucial to identify early signs of infection post-surgery. Redness, swelling, warmth, or discharge at the surgical site can indicate an infection. While monitoring for fever (choice B) is important as fever can also be a sign of infection, it may not always present immediately post-surgery. Checking blood pressure (choice C) is essential for other purposes but not specifically for monitoring infection post-surgery. Checking for redness (choice D) is limited as redness alone may not always indicate an infection, so it is not as comprehensive as monitoring the surgical site.

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