how should a nurse monitor fluid balance in a patient receiving diuretics

ATI RN

ATI RN Exit Exam 2023

1. How should fluid balance be monitored in a patient receiving diuretics?

A. Monitor daily weight
B. Monitor intake and output
C. Check for edema
D. Monitor blood pressure

Correct answer: A

Rationale: Corrected Question: To assess fluid balance in a patient receiving diuretics, monitoring daily weight is the most accurate method. This is because diuretics primarily affect fluid levels in the body, leading to changes in weight due to fluid loss. While monitoring intake and output, checking for edema, and monitoring blood pressure are important aspects of patient care, they do not provide as direct and accurate information about fluid balance as daily weight monitoring specifically in patients on diuretics.

2. What is the best intervention for a patient with respiratory distress?

A. Administer oxygen
B. Administer bronchodilators
C. Administer IV fluids
D. Administer corticosteroids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In respiratory distress, the priority intervention is to improve oxygenation. Administering oxygen helps increase the oxygen levels in the blood, supporting respiratory function. While bronchodilators may be used in specific respiratory conditions like asthma or COPD, they are not the primary intervention for respiratory distress. IV fluids are not indicated as the initial treatment for respiratory distress unless there is an underlying cause such as dehydration. Corticosteroids may be used in certain respiratory conditions to reduce inflammation, but they are not the first-line intervention for acute respiratory distress.

3. A client has a new ileostomy. Which of the following actions should the nurse take?

A. Apply a skin barrier around the stoma.
B. Empty the pouch when it is one-third full.
C. Change the entire pouching system weekly.
D. Cleanse the peristomal skin with alcohol.

Correct answer: C

Rationale: Changing the entire pouching system weekly is essential for maintaining skin integrity and preventing infection. Option A is incorrect as applying a skin barrier should be done during the pouch change, not separately. Option B is incorrect as ileostomy pouches should be emptied when they are one-third to one-half full to prevent leakage. Option D is incorrect because cleansing the peristomal skin with alcohol can be too harsh and may cause skin irritation.

4. A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

A. Blood glucose of 110 mg/dL.
B. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
C. WBC count of 6,500/mm3.
D. Temperature of 37.3Â°C (99.1Â°F).

Correct answer: B

Rationale: A weight loss of 0.5 kg (1.1 lb) in 24 hours may indicate dehydration or malnutrition, which are critical concerns for a client receiving total parenteral nutrition (TPN). Therefore, the nurse should report this finding to the provider. Elevated blood glucose levels (Choice A) can be managed by adjusting TPN components, WBC count (Choice C) and a slightly elevated temperature (Choice D) are not directly related to TPN administration and may not require immediate intervention.

5. A client with a history of depression and experiencing a situational crisis is being assessed by a nurse. What action should the nurse take first?

A. Notify the client's support system.
B. Help the client identify personal strengths.
C. Confirm the client's perception of the event.
D. Teach the client relaxation techniques.

Correct answer: A

Rationale: When a client with a history of depression is experiencing a situational crisis, the first action the nurse should take is to notify the client's support system. This is crucial as the client may require immediate assistance and support. While helping the client identify personal strengths and confirming the client's perception of the event are important aspects of the assessment and intervention process, notifying the support system takes priority in ensuring the client's safety and well-being. Teaching relaxation techniques may be beneficial but addressing the client's immediate crisis through support system notification is the most appropriate initial action.