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. Which medication is used to reverse the effects of opioid overdose?

A. Naloxone
B. Epinephrine
C. Atropine
D. Lidocaine

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is specifically used to reverse the effects of opioid overdose by binding to opioid receptors and blocking the effects of opioids. Epinephrine is mainly used to treat severe allergic reactions, Atropine is used for certain types of heart conditions and to reduce salivation or respiratory secretions, and Lidocaine is a local anesthetic used for numbing purposes. Therefore, choices B, C, and D are incorrect in the context of reversing opioid overdose.

3. A client who has a new prescription for alendronate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

A. I should take this medication with a full glass of water before breakfast.
B. I should take this medication with food to prevent gastrointestinal upset.
C. I should remain upright for at least 30 minutes after taking this medication.
D. I should avoid taking this medication with antacids.

Correct answer: C

Rationale: The correct answer is C: "I should remain upright for at least 30 minutes after taking this medication." This statement indicates understanding because clients taking alendronate should remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Choice A is incorrect because alendronate should be taken with a full glass of water after waking up, not before breakfast. Choice B is incorrect because alendronate should be taken on an empty stomach, not with food. Choice D is incorrect because alendronate should be taken separately from antacids.

4. A client has deep vein thrombosis (DVT). Which of the following actions should the nurse take?

A. Administer thrombolytics as prescribed.
B. Massage the affected extremity every 2 hours.
C. Apply warm compresses to the affected extremity.
D. Place the client in a supine position with the legs elevated.

Correct answer: C

Rationale: The correct action for a nurse caring for a client with deep vein thrombosis (DVT) is to apply warm compresses to the affected extremity. Warm compresses help reduce swelling and pain in clients with DVT. Administering thrombolytics (Choice A) is not typically done without specific orders due to the risk of bleeding. Massaging the affected extremity (Choice B) can dislodge blood clots and lead to complications. Placing the client in a supine position with the legs elevated (Choice D) may increase the risk of clot dislodgment.

5. A client has a new prescription for furosemide. Which of the following instructions should the nurse include?

A. Avoid foods high in potassium while taking this medication.
B. This medication may cause your blood pressure to increase.
C. This medication can cause you to retain fluids.
D. Take this medication with meals.

Correct answer: D

Rationale: The correct instruction for a client taking furosemide is to take the medication with meals. This helps prevent gastrointestinal upset and improves medication tolerance. Option A is incorrect because furosemide is a loop diuretic that can cause potassium depletion, so avoiding foods high in potassium is not necessary. Option B is incorrect as furosemide typically lowers blood pressure. Option C is incorrect because furosemide is a diuretic that promotes fluid loss rather than retention.