what is the priority intervention for a patient with fluid overload

ATI RN

ATI Exit Exam RN

1. What is the priority intervention for a patient with fluid overload?

A. Administer diuretics
B. Administer IV fluids
C. Provide oral fluids
D. Provide chest physiotherapy

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.

2. A client is prescribed furosemide and needs to consume potassium-rich foods. Which of the following foods should the client be advised to include in the diet?

A. Grapes.
B. Apples.
C. Bananas.
D. Rice.

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are rich in potassium and should be included in the diet of clients taking furosemide, a potassium-wasting diuretic. Grapes, apples, and rice are not as high in potassium as bananas and would not be as effective in replenishing potassium levels in clients taking furosemide.

3. Which electrolyte imbalance is most concerning in a patient on furosemide?

A. Hyperkalemia
B. Hypokalemia
C. Hyponatremia
D. Hypercalcemia

Correct answer: B

Rationale: The correct answer is Hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion by increasing its excretion in the urine. Hypokalemia is a common and concerning side effect of furosemide therapy. Hyperkalemia (Choice A) is less likely as furosemide tends to lower potassium levels. Hyponatremia (Choice C) is more commonly seen with thiazide diuretics. Hypercalcemia (Choice D) is not directly associated with furosemide use.

4. A healthcare professional is assessing a client who has a new prescription for digoxin. Which of the following findings is the priority for the healthcare professional to report to the provider?

A. Heart rate of 58/min
B. Weight gain of 1 kg (2.2 lb) in 24 hours
C. Respiratory rate of 20/min
D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: The correct answer is A. A heart rate of 58/min is indicative of bradycardia, a potential sign of digoxin toxicity, which should be reported immediately. While weight gain, respiratory rate, and temperature are important parameters to monitor, they are not as critical as identifying bradycardia in a client taking digoxin.

5. A nurse is caring for a client who is postpartum and reports perineal pain. Which intervention should the nurse implement?

A. Administer analgesics as prescribed.
B. Apply a warm compress to the perineum.
C. Encourage the client to ambulate frequently.
D. Position the client with the head elevated.

Correct answer: A

Rationale: Administering analgesics as prescribed is the appropriate intervention for managing perineal pain in a postpartum client. Analgesics help to alleviate discomfort and promote the client's recovery. Applying a warm compress (choice B) may provide some relief, but it does not address the pain as effectively as analgesics. Encouraging ambulation (choice C) and positioning the client with the head elevated (choice D) are not directly related to addressing perineal pain.