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. A nurse is reviewing the medication orders for a client with heart failure. Which of the following medications should the nurse clarify with the provider?

Correct answer: D

Rationale: The correct answer is D, Ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can worsen heart failure due to its effects on renal function and fluid retention. Therefore, the nurse should clarify the use of Ibuprofen with the provider. Choices A, B, and C (Furosemide, Spironolactone, and Digoxin) are commonly prescribed medications for heart failure that help manage symptoms and improve cardiac function, so they do not need clarification in this scenario.

3. What is the recommended procedure for a healthcare professional to follow when applying sterile gloves?

Correct answer: D

Rationale: The correct procedure for applying sterile gloves is to do so before touching any sterile equipment or surfaces. This helps maintain the sterility of the gloves. Choices A, B, and C are incorrect because they suggest incorrect sequences that may compromise the sterility of the gloves. Using non-sterile gloves first can introduce contamination, putting on gloves before a gown can lead to contamination of the gloves during gowning, and applying gloves after donning a mask can risk contamination of the gloves from the mask.

4. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

5. A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?

Correct answer: B

Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.

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