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 most critical lab value to monitor for a patient on heparin therapy?

A. Monitor aPTT levels
B. Monitor platelet count
C. Monitor INR levels
D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT levels. Activated Partial Thromboplastin Time (aPTT) is crucial for assessing the therapeutic effectiveness of heparin, as it reflects the intrinsic pathway of the coagulation cascade. Monitoring aPTT helps ensure that the patient is within the therapeutic range of heparin, minimizing the risk of bleeding complications. Platelet count (choice B) is important to assess for potential heparin-induced thrombocytopenia but is not the primary lab value to monitor during heparin therapy. INR levels (choice C) are monitored in patients on warfarin therapy, not heparin. Sodium levels (choice D) are not directly related to heparin therapy monitoring.

3. A nurse is providing discharge instructions to a client who has tuberculosis and a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching?

A. I should have my vision checked regularly while taking this medication.
B. This medication can cause my urine to turn reddish-orange.
C. I need to wear sunscreen and protective clothing while taking this medication.
D. I will discontinue this medication if I experience nausea.

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause a harmless reddish-orange discoloration of body fluids, including urine. Choice A is not related to rifampin; vision changes are not a common side effect of the medication. Choice C is more relevant to medications that cause photosensitivity reactions, not specifically rifampin. Choice D is incorrect because nausea is a common side effect of rifampin, but it does not warrant immediate discontinuation of the medication.

4. A nurse is caring for a client who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

A. WBC 4,500/mm3
B. Hemoglobin 12 g/dL
C. Platelet count 250,000/mm3
D. Platelet count 100,000/mm3

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm3 is lower than the normal range, indicating thrombocytopenia, which is concerning in clients receiving chemotherapy. Thrombocytopenia can lead to an increased risk of bleeding and bruising. Choices A, B, and C fall within the normal range and would not be a cause for concern in a client receiving chemotherapy.

5. How should fluid balance be assessed 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 Rationale: Monitoring daily weight is the most accurate method to assess fluid balance in patients receiving diuretics. Changes in weight reflect changes in fluid balance, making it a sensitive indicator. Monitoring intake and output (choice B) is important but may not provide a complete picture of overall fluid balance. Checking for edema (choice C) is a late sign of fluid imbalance and may not be sensitive enough to detect subtle changes. Monitoring blood pressure (choice D) is relevant but may not directly reflect fluid balance as it can be influenced by various other factors.