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. How should pain be assessed in a non-verbal patient?

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

3. A nurse is providing teaching about newborn care to a group of parents. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D: 'You should keep your newborn's head elevated while they sleep.' Keeping the newborn's head elevated while sleeping helps prevent conditions like sudden infant death syndrome (SIDS). Choice A is incorrect because newborns do not need to be bathed every day; it is recommended to bathe them 2-3 times a week. Choice B is incorrect as heavy blankets can increase the risk of suffocation for newborns. Choice C is incorrect as newborn stools are typically soft and yellow in color, not firm and light brown.

4. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse implement?

Correct answer: C

Rationale: Elevating the head of the bed reduces pressure on bony prominences, which helps prevent pressure ulcers.

5. A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Corrected Rationale: Providing information about stress management is essential when caring for a client with Raynaud's disease because stress can trigger episodes. Stress management techniques can help the client avoid triggers and reduce the frequency of episodes. Choice B is incorrect because maintaining a warm temperature, rather than a cool one, helps prevent vasoconstriction and can be beneficial for clients with Raynaud's disease. Choice C is incorrect because epinephrine is not a standard treatment for Raynaud's disease; it is more commonly used for severe allergic reactions. Choice D is incorrect because glucocorticoid steroids are not typically used in the management of Raynaud's disease.

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