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

ATI RN

ATI Exit Exam RN

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

A. Administer diuretics
B. Increase fluid intake
C. Provide oral fluids
D. Provide chest physiotherapy

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 nurse is providing discharge teaching to a client with type 2 diabetes mellitus. Which of the following resources should the nurse provide?

A. Personal blogs about managing diabetes medications.
B. Food label recommendations from the Institute of Medicine.
C. Diabetes medication information from the Physicians' Desk Reference.
D. Food exchange lists for meal planning from the American Diabetes Association.

Correct answer: D

Rationale: The correct answer is D. Food exchange lists are valuable resources for individuals with diabetes as they provide structured meal planning guidance. This helps individuals manage their diabetes effectively by controlling their carbohydrate intake. Choices A, B, and C are incorrect because personal blogs may not provide reliable and evidence-based information, food label recommendations from the Institute of Medicine may not be specific for diabetes meal planning, and diabetes medication information from the Physicians' Desk Reference is not directly related to meal planning for diabetes management.

3. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following sites should the healthcare provider select?

A. Deltoid
B. Vastus lateralis
C. Rectus femoris
D. Dorsogluteal

Correct answer: B

Rationale: The vastus lateralis is the preferred site for intramuscular injections in adults due to its large muscle mass and low risk of complications. The deltoid, although a common site for vaccines, has a smaller muscle mass and may not be suitable for all types of medications. The rectus femoris is a muscle in the thigh that is more commonly used for intramuscular injections in infants. The dorsogluteal site is no longer recommended due to its proximity to major nerves and blood vessels.

4. A nurse is caring for a client who is in labor and is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

A. Fetal hypoxia
B. Head compression
C. Placenta previa
D. Umbilical cord prolapse

Correct answer: B

Rationale: In the scenario of early decelerations noted during labor with electronic fetal monitoring, the nurse should expect head compression. Early decelerations are a normal response to fetal head compression during contractions and are not indicative of fetal distress. Choice A, fetal hypoxia, is incorrect as early decelerations are not associated with fetal oxygen deprivation. Choices C and D, placenta previa and umbilical cord prolapse, are unrelated to the scenario described and do not cause early decelerations.

5. What should be monitored when administering opioids to a patient?

A. Monitor blood pressure
B. Monitor respiratory rate
C. Monitor heart rate
D. Monitor oxygen saturation

Correct answer: B

Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.