what is the best nursing intervention for a patient experiencing fluid overload
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. What is the best nursing intervention for a patient experiencing fluid overload?

Correct answer: A

Rationale: The best nursing intervention for a patient experiencing fluid overload is to administer diuretics. Diuretics help the body to remove excess fluid by increasing urine output. This intervention is crucial in managing fluid overload. Administering IV fluids (Choice B) would worsen the condition by adding more fluids to the already overloaded system. Providing oral fluids (Choice C) is not appropriate as it would further contribute to the fluid overload. Chest physiotherapy (Choice D) is not indicated in the treatment of fluid overload and would not address the underlying issue of excess fluid accumulation.

2. A nurse is reviewing laboratory results for a client who has rheumatoid arthritis and is prescribed methotrexate. Which of the following results should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D: Aspartate aminotransferase (AST) 60 units/L. An elevated AST level indicates liver damage, which can be a side effect of methotrexate and should be reported. Elevated white blood cell count (choice A), platelet count (choice B), or normal hemoglobin level (choice C) are not directly related to methotrexate therapy for rheumatoid arthritis.

3. What is the best intervention for a patient experiencing respiratory distress?

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is crucial in ensuring that the patient receives an adequate supply of oxygen to meet the body's demands. Administering bronchodilators (Choice B) may be beneficial in specific respiratory conditions like asthma or COPD but may not be the primary intervention in all cases of respiratory distress. Administering IV fluids (Choice C) may be necessary in cases of dehydration or shock but would not directly address respiratory distress. Providing chest physiotherapy (Choice D) can help mobilize secretions in conditions like cystic fibrosis but is not the first-line intervention for respiratory distress.

4. How should a healthcare professional administer a subcutaneous injection?

Correct answer: A

Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.

5. How should a healthcare professional prepare a patient for a colonoscopy?

Correct answer: D

Rationale: Giving a bowel prep solution is essential to clean out the colon thoroughly before a colonoscopy. This process is crucial as it helps to achieve a clear view of the colon during the procedure. Providing clear instructions on diet (Choice A) and ensuring the patient has an empty stomach (Choice C) are important steps in the preparation process but may not be sufficient on their own to adequately cleanse the colon. Explaining the procedure in detail (Choice B) is helpful for patient education but does not directly contribute to the physical preparation required for a successful colonoscopy.

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