how should a nurse monitor fluid balance in a patient with heart failure how should a nurse monitor fluid balance in a patient with heart failure
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Nursing Elites

ATI RN

ATI RN Exit Exam Test Bank

1. How should fluid balance in a patient with heart failure be monitored?

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

2. A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

Correct answer: B

Rationale: Tuberculosis is spread through small droplets measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has TB under airborne precautions to prevent the spread of microbes. Choice A, contact precautions, are used for diseases spread by direct or indirect contact. Choice C, droplet precautions, are for diseases spread by larger droplets. Choice D, protective environment, is used for immunocompromised clients to protect them from environmental pathogens.

3. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?

Correct answer: Infection

Rationale:

4. A male college student begins feeling sad and lonely. Although still able to go to classes and work at his job, he finds himself feeling down much of the time and worrying about what is happening to him. Which part of the definition of abnormality applies to his situation?

Correct answer: A

Rationale: The correct answer is A: Personal distress. In this scenario, the student is experiencing personal distress as he feels sad and lonely, despite being able to function in his daily life. Personal distress is a key criterion for determining abnormality as it signifies significant emotional discomfort. Choices B, C, and D are incorrect as cultural factors, impaired functioning, and violation of societal norms are not the primary factors highlighted in the student's situation.

5. A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?

Correct answer: Checks the blood identification numbers with the laboratory technician at the Blood Bank at the time it is dispersed

Rationale: Ensuring the safety of a blood transfusion is crucial to prevent potential errors or adverse reactions. Checking the blood identification numbers with the laboratory technician at the Blood Bank when the blood is dispersed helps confirm that the correct blood product is being administered to the right patient, reducing the risk of transfusion reactions. The other choices are incorrect because asking the client to say and spell their full name (Choice A) is a part of the identification process but not specific to ensuring the safety of the blood transfusion. While having another qualified healthcare professional check the unit (Choice B) is a good practice, the direct verification with the Blood Bank technician is a more critical step in ensuring the correct blood product is administered. Choice D is irrelevant to ensuring the safety of the blood transfusion as it addresses infection control measures.

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