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 client in active labor has ruptured membranes. What action should the nurse take?

A. Apply a fetal heart rate monitor.
B. Initiate fundal massage.
C. Administer oxytocin IV.
D. Insert an indwelling urinary catheter.

Correct answer: A

Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.

3. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

A. Perform perineal care before the procedure.
B. Apply sterile gloves before cleansing the perineal area.
C. Place the client in a supine position.
D. Lubricate the catheter with alcohol-based gel.

Correct answer: B

Rationale: Before inserting an indwelling urinary catheter for a female client, the nurse should apply sterile gloves before cleansing the perineal area to prevent infection. Performing perineal care before the procedure is incorrect as it should be done after catheter insertion. Placing the client in a side-lying position is not necessary for this procedure. Lubricating the catheter with petroleum jelly is not recommended as it can damage the catheter; using a water-soluble lubricant is preferred.

4. What is the first action to take when a patient experiences a seizure?

A. Protect the patient from injury
B. Administer oxygen
C. Administer IV fluids
D. Administer anti-seizure medication

Correct answer: A

Rationale: The first action to take when a patient experiences a seizure is to protect the patient from injury. This is crucial to prevent harm during the seizure. Administering oxygen, IV fluids, or anti-seizure medication may be necessary based on the patient's condition, but ensuring their safety by removing harmful objects, cushioning their head, and keeping the area clear is the immediate priority. Administering oxygen, IV fluids, or medication would come after ensuring the patient's safety.

5. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

A. Place the infant under a radiant warmer
B. Move the probe site every 3 hours
C. Heat the skin one minute prior to placing the probe
D. Place a sensor on the index finger

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.