which outcome should the nurse identify for the client diagnosed with fluid volume excess

ATI RN

ATI RN Custom Exams Set 4

1. Which outcome should the nurse identify for the client diagnosed with fluid volume excess?

A. The client will void a minimum of 30 mL per hour
B. The client will have elastic skin turgor
C. The client will have no adventitious breath sounds
D. The client will have a serum creatinine of 1.4 mg/dL

Correct answer: C

Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.

2. What is the combat health support system in the field designed to do?

A. Provide evacuation to the far rear for treatment and delay return to duty
B. Project, sustain, and protect the health of the soldier in war and operations other than war
C. Provide rearward evacuation and reassignment
D. Provide far rear area care and delayed return to duty

Correct answer: B

Rationale: The correct answer is B. The combat health support system in the field is designed to project, sustain, and protect the health of soldiers in both war and operations other than war. Choice A is incorrect because the system is not primarily focused on providing evacuation to the far rear for treatment, but rather on overall health support. Choice C is incorrect as it only mentions rearward evacuation and reassignment, which is a limited scope compared to the comprehensive support provided by the system. Choice D is incorrect as it narrowly focuses on far rear area care and delayed return to duty, missing the broader aspects of health support and protection.

3. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?

A. “I should increase fruits, bran, and fluids in my diet.”
B. “I will use warm compresses and take sitz baths daily.”
C. “I must take a laxative every night and have a stool daily.”
D. “I can use an analgesic ointment or suppository for pain.”

Correct answer: C

Rationale: Choice C indicates that further teaching is needed because taking a laxative every night and aiming to have a stool daily can lead to dependence and is not recommended for managing hemorrhoids. Choices A, B, and D are appropriate self-care measures for hemorrhoids, such as increasing fiber intake, using warm compresses/sitz baths, and using analgesic ointments or suppositories for pain relief.

4. What causes hepatic encephalopathy?

A. Buildup of ammonia in the body
B. Buildup of urea in the body
C. Fatty infiltration of the liver
D. Jaundice

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body, not urea. Ammonia accumulates due to liver dysfunction, leading to neurological symptoms. Fatty infiltration of the liver may lead to conditions like non-alcoholic fatty liver disease, but it is not the direct cause of hepatic encephalopathy. Jaundice is a symptom of liver dysfunction but is not the primary cause of hepatic encephalopathy.

5. One potential side effect associated with the use of nonsteroidal anti-inflammatory drugs is:

A. Stomach irritation and bleeding
B. Stomatitis and esophagitis
C. Impaired folate absorption
D. Increased potassium excretion

Correct answer: A

Rationale: The correct answer is A: Stomach irritation and bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) can lead to stomach irritation and bleeding by affecting the gastric mucosa. Stomatitis and esophagitis (choice B) are not commonly associated with NSAIDs. Impaired folate absorption (choice C) is not a typical side effect of NSAIDs. Increased potassium excretion (choice D) is not a common side effect of NSAIDs.