a client with a serum albumin level of 3 gdl has a pressure ulcer what should the nurse do first
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. A client with a serum albumin level of 3 g/dL has a pressure ulcer. What should the nurse do first?

Correct answer: B

Rationale: The correct first action for a client with a serum albumin level of 3 g/dL and a pressure ulcer is to consult a dietitian to improve the client's nutritional status. Adequate nutrition is essential for wound healing. Monitoring fluid and electrolyte balance is important but not the first priority in this situation. Administering a protein supplement can be considered after dietary evaluation. Administering an anti-inflammatory medication is not the primary intervention for addressing a pressure ulcer related to low albumin levels.

2. What is the best nursing intervention for a patient with hyperkalemia?

Correct answer: A

Rationale: The correct answer is to administer potassium-wasting diuretics. Hyperkalemia, which is high potassium levels, is managed by promoting the excretion of potassium from the body. Potassium-wasting diuretics help the kidneys eliminate excess potassium. Encouraging a low-potassium diet (choice B) is important for long-term management but not the immediate intervention for hyperkalemia. Administering potassium supplements (choice C) would worsen the condition by further increasing potassium levels. Administering IV fluids (choice D) may help with hydration but does not directly address the high potassium levels characteristic of hyperkalemia.

3. How should a healthcare professional assess a patient with fluid overload?

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

4. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

5. Which intervention is essential when caring for a client with heart failure on fluid restriction?

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily to assess fluid balance.' When caring for a client with heart failure on fluid restriction, it is essential to monitor their weight daily to evaluate fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink water throughout the day contradicts fluid restriction. Limiting fluid intake during meals may not provide a comprehensive assessment of fluid balance, and weighing the client once a week is not frequent enough to detect rapid changes in fluid status that could worsen heart failure symptoms.

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