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

ATI RN

ATI RN Custom Exams Set 4

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

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. A 31-year-old client is seeking contraceptive information. Before responding to the client’s questions about contraceptives, the nurse obtains a health history. What factor in the client’s history indicates to the nurse that oral contraceptives are contraindicated?

Correct answer: C

Rationale: The correct answer is C. Smoking, especially in clients over 30, increases the risk of thromboembolic events, making oral contraceptives contraindicated. Choice A is incorrect as age alone is not a contraindication for oral contraceptives. Choice B is incorrect as having multiple pregnancies is not a contraindication for oral contraceptives. Choice D is incorrect as borderline hypertension is not a strict contraindication for oral contraceptives.

3. Which dietary change is most beneficial for a patient with hypertension?

Correct answer: C

Rationale: The correct answer is C: Increased fiber intake. A diet high in fiber is beneficial for patients with hypertension as it helps lower blood pressure. Increasing fiber intake can aid in managing hypertension by promoting heart health and overall well-being. Choices A, B, and D are incorrect. Increased sodium intake is not recommended for hypertension as it can elevate blood pressure. Decreasing potassium intake is also not advised as potassium is essential for regulating blood pressure. Lastly, increasing cholesterol intake is detrimental for hypertension as it can contribute to cardiovascular issues and worsen the condition.

4. At the end of the Practical Nurse Course, the student receives a structured review to prepare the student for which of the following?

Correct answer: D

Rationale: The structured review at the end of the Practical Nurse Course aims to prepare students for the practical nurse licensure examination. This exam is a crucial step for individuals to become licensed practical nurses, ensuring they meet the required standards and qualifications to practice in the field. Choices A, B, and C are incorrect as the focus of the review is specifically geared towards preparing students for the licensure examination, not for other courses, administrative processes, or duty assignments.

5. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?

Correct answer: B

Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (choice A) is not directly related to monitoring or managing ovarian hyperstimulation. Explaining the duration of infusion therapy (choice C) is not relevant to the potential complication of ovarian hyperstimulation. Discussing the risk of ectopic pregnancy (choice D) is important but not the most appropriate intervention for managing ovarian hyperstimulation.

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