a client is at risk for excess fluid volume which nursing intervention ensures the most accurate monitoring of the clients fluid status
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

Correct answer: B

Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.

2. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

Correct answer: D

Rationale: When a nurse has developed a close relationship with a dying client's family, it is crucial to provide comprehensive support. Encouraging family discussion of feelings helps them express their emotions and concerns, fostering a sense of relief. Accepting the family's experience of anger without judgment validates their emotions and promotes trust. Facilitating the use of spiritual practices identified by the family acknowledges their beliefs and values, offering comfort and solace. Therefore, all of the above interventions are essential in providing holistic care and support during such a challenging time. Choices A, B, and C each play a vital role in addressing different aspects of the family's emotional and spiritual needs, making option D the correct answer.

3. A client who is postpartum and diagnosed with iron deficiency anemia is receiving education from a nurse. Which dietary recommendation should be included in the education plan?

Correct answer: B

Rationale: The correct answer is B: Spinach and beef. Spinach is a good source of non-heme iron, while beef provides heme iron, both essential for treating iron deficiency anemia. Yogurt and mozzarella (choice A) are not significant sources of iron. Fish and cottage cheese (choice C) do not provide as much iron as spinach and beef. Turkey slices and milk (choice D) are also not as rich in iron compared to spinach and beef.

4. Which type of diet is recommended for patients with diverticulitis during an acute flare-up?

Correct answer: B

Rationale: During an acute flare-up of diverticulitis, a low-residue diet is recommended. This diet helps reduce bowel movements and minimizes irritants in the colon, which can help alleviate symptoms and promote healing. High-fiber diets, like choice A, are typically recommended for diverticulosis prevention but may exacerbate symptoms during a flare-up due to increased bulk in the stool. Low-fat (choice C) and high-protein (choice D) diets are not specifically indicated for diverticulitis flare-ups.

5. The nurse is caring for the client one day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

Correct answer: D

Rationale: Assisting the client to sit in a chair is an essential nursing intervention postoperatively as it helps promote circulation, prevent complications like blood clots, and aids in the recovery process. Changing the infusion rate of intravenous fluid (Choice A) requires a physician's order and is not an independent nursing intervention. Encouraging the client to discuss feelings (Choice B) is important for emotional support but not as crucial as physical care immediately postoperatively. Administering opioid narcotic medications (Choice C) for pain management should be based on a prescribed schedule and assessment rather than being an independent nursing action.

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