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

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 caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.

3. Which of the following is a critical nursing action when managing a patient with a chest tube?

Correct answer: B

Rationale: The correct answer is B: "Ensure the chest tube is connected to a closed drainage system." This is a critical nursing action when managing a patient with a chest tube because it is essential for proper drainage and to prevent complications such as air leaks or infections. Option A is incorrect because keeping the chest tube clamped at all times would prevent proper drainage and could lead to complications. Option C is incorrect as emptying the chest tube drainage system should be done based on assessment findings rather than a fixed time interval. Option D is incorrect because disconnecting the chest tube when the patient is ambulating can lead to complications like a pneumothorax.

4. A client with neuropathic pain has a new prescription for amitriptyline once per day. What should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B: 'Increase fluids while on this medication.' Amitriptyline can cause side effects like dry mouth and urinary retention. Increasing fluids can help alleviate these side effects. Choices A, C, and D are incorrect. Taking the medication with meals or only at night is not specifically related to managing the side effects of amitriptyline. Reporting yellowing of the skin is important but not directly related to the side effects of this medication.

5. A client with cirrhosis and ascites requires a care plan. Which intervention should the nurse include?

Correct answer: D

Rationale: In cirrhosis with ascites, decreasing fluid intake is crucial to manage the condition. This helps prevent further fluid accumulation in the abdomen. Increasing sodium intake (Choice A) can worsen fluid retention and edema. Increasing saturated fat intake (Choice B) is not recommended as it can contribute to liver damage. Decreasing carbohydrate intake (Choice C) is not directly related to managing ascites in cirrhosis.

Similar Questions

A nurse is caring for a client who had a total thyroidectomy and has a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?
A client with a urinary tract infection is prescribed ciprofloxacin. Which instruction should the nurse provide?
A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?
A healthcare professional is reviewing the medical record of a client who received their medications 1 hour ago. The client reports chest pain. This can be an adverse effect of what medication?
A client is vomiting, and a nurse is providing care. Which of the following actions should the nurse take first?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses