nurse is planning care for a client who has fluid overload which of the following actions should the nurse plan to take first
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. A healthcare provider is planning care for a client who has fluid overload. Which of the following actions should the provider plan to take first?

Correct answer: B

Rationale: Evaluating electrolytes is crucial when addressing fluid overload as it helps determine the severity of the imbalance and guides treatment. Assessing for edema (Choice A) is important but not the priority over evaluating electrolytes. Restricting fluid intake (Choice C) and administering diuretics (Choice D) are interventions that may be necessary but should be based on the electrolyte evaluation to ensure safe and effective care.

2. How should a healthcare provider manage a patient with deep vein thrombosis (DVT)?

Correct answer: A

Rationale: Corrected Rationale: Monitoring for signs of pulmonary embolism is crucial in patients with deep vein thrombosis (DVT) as it can be a life-threatening complication. While administering anticoagulants as prescribed is important for preventing clot progression, the immediate concern is detecting potential pulmonary embolism. Applying compression stockings and encouraging leg elevation are beneficial measures for managing DVT symptoms but are not as critical as monitoring for pulmonary embolism.

3. How is the effectiveness of a diuretic in a patient with heart failure evaluated?

Correct answer: A

Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.

4. A client reports severe pain unrelieved by pain medication in a limb with traction. What is the nurse's priority?

Correct answer: B

Rationale: The correct answer is B: Assess for compartment syndrome. Severe unrelieved pain in a limb with traction can be a sign of compartment syndrome, a surgical emergency. Prompt assessment is crucial to prevent potential complications. Increasing pain medication dosage without addressing the underlying cause may delay necessary interventions. Waiting for the healthcare provider may lead to a critical delay in treatment. Repositioning the client may not alleviate the pain if it is due to compartment syndrome, and it is crucial to assess for this condition first.

5. A nurse is preparing to administer a blood transfusion. What is the most important action to ensure patient safety?

Correct answer: B

Rationale: The most important action to ensure patient safety when administering a blood transfusion is to verify the patient's identity with two identifiers before starting the transfusion. This step is crucial to prevent transfusion errors, such as giving the blood to the wrong patient. Checking vital signs, ensuring timely administration, and confirming informed consent are also important aspects of blood transfusion safety but verifying the patient's identity is the highest priority to prevent errors.

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