what are the signs and symptoms of fluid overload

ATI LPN

ATI PN Comprehensive Predictor

1. What are the signs and symptoms of fluid overload?

A. Edema, shortness of breath, weight gain
B. High blood pressure and jugular venous distention
C. Low blood pressure and cyanosis
D. Tachycardia and dizziness

Correct answer: A

Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.

2. A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

A. Pupils constrict when shifting gaze from near to far
B. Pupils constrict when shifting gaze from far to near
C. Lack of change in pupil size when shifting gaze from near to far
D. Lack of change in pupil size when shifting gaze from far to near

Correct answer: D

Rationale: Pupil accommodation problems are indicated by the lack of change in size when shifting gaze from far to near. The correct answer is D because in pupil accommodation, the pupils should constrict when shifting gaze from far to near in order to adjust for near vision. Choices A and B describe normal responses of pupil constriction when shifting gaze, which do not indicate a problem. Choice C is incorrect as it describes a normal response of pupil size change when shifting gaze from near to far.

3. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?

A. Encourage the client to rest and let the healthcare team take over self-care tasks
B. Instruct the client to gradually resume self-care tasks, with rest periods
C. Assign assistive personnel to complete self-care tasks for the client
D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.

4. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

A. Encourage the client to eat high-protein foods
B. Encourage the client to drink 2 liters of fluid daily
C. Instruct the client to use a soft toothbrush
D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

5. How should a healthcare professional manage a patient with a tracheostomy?

A. Monitor airway patency and provide humidified oxygen
B. Provide education on tracheostomy care
C. Suction airway secretions and change tracheostomy ties
D. Provide a high-protein diet and ensure fluid restriction

Correct answer: A

Rationale: Correct answer: Monitoring airway patency and providing humidified oxygen is crucial in managing a patient with a tracheostomy to ensure proper breathing and oxygenation. Ensuring the airway is clear and providing oxygen support are immediate priorities. Providing education on tracheostomy care (Choice B) is important for long-term management but not the immediate priority. Suctioning airway secretions and changing tracheostomy ties (Choice C) are tasks that may be necessary but do not address the primary concern of maintaining airway patency. Providing a high-protein diet and ensuring fluid restriction (Choice D) are unrelated to the immediate management of a tracheostomy.