the nurse is preparing the plan of care for a client with fluid volume deficit which interventions should the nurse include in the plan of care
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

2. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?

Correct answer: A

Rationale: When collecting a mid-stream clean catch urine specimen for urine analysis, it is important to collect an adequate amount of urine for accurate testing. A volume of 30 to 60 ml is usually recommended for optimal results, so collecting only 5 to 10 ml would not provide enough urine for testing purposes. It is essential to follow proper collection techniques to ensure accurate and reliable test results.

3. The best position for any procedure that involves vaginal and cervical examination is

Correct answer: D

Rationale: The lithotomy position is the most suitable position for procedures involving vaginal and cervical examination because it provides the best access to the vaginal and cervical regions. In this position, the patient lies on their back with their legs flexed and feet placed in stirrups, allowing for optimal visualization and access to the area. This position facilitates proper examination, diagnosis, and treatment when working in the gynecological field. The other options (dorsal recumbent, side lying, and supine) do not provide the same level of access and visualization as the lithotomy position, making them less ideal for vaginal and cervical examinations.

4. Which of the following is a process of heat loss that involves the transfer of heat from one surface to another?

Correct answer: B

Rationale: Conduction is the process of heat transfer that occurs between objects or substances that are in direct contact with each other. In this process, heat is transferred from a hotter surface to a cooler surface through direct contact. This type of heat transfer does not involve the movement of the substances themselves, only the transfer of thermal energy. Radiation (Choice A) is the transfer of heat through electromagnetic waves, while convection (Choice C) is the transfer of heat through the movement of fluids. Evaporation (Choice D) is a cooling process that involves the phase change of a liquid into a gas.

5. A patient with Crohn’s disease is experiencing diarrhea. Which dietary recommendation is appropriate?

Correct answer: B

Rationale: A low-residue diet is the appropriate dietary recommendation for a patient with Crohn’s disease experiencing diarrhea. This diet helps reduce bowel movements and manage diarrhea by limiting the intake of foods that are harder to digest. High-fiber diets (Choice A) may worsen diarrhea due to increased bulk in the stool. High-fat diets (Choice C) can be harder to digest and may exacerbate symptoms. High-protein diets (Choice D) are not specifically recommended for managing diarrhea in Crohn’s disease.

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