how should a nurse assess fluid balance in a patient with heart failure

ATI RN

ATI Exit Exam RN

1. How should fluid balance be assessed in a patient with heart failure?

A. Monitor daily weight
B. Monitor input and output
C. Check for edema
D. Monitor blood pressure

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

2. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?

A. Position the client with the affected extremity higher than the heart
B. Administration of acetaminophen
C. Massage the affected extremity every 4 hours
D. Withhold heparin IV infusion

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.

3. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

A. Store the glasses in a labeled case
B. Clean the glasses with hot water
C. Clean the glasses with a paper towel
D. Store the glasses on the bedside table

Correct answer: A

Rationale: The correct action for the nurse to take is to store the glasses in a labeled case. This ensures the safety of the glasses and helps in their proper identification when needed. Cleaning the glasses with hot water (Choice B) can damage them, and using a paper towel (Choice C) can scratch the lenses. Storing the glasses on the bedside table (Choice D) can lead to misplacement or damage. Therefore, the most appropriate action is to store the glasses in a labeled case.

4. A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?

A. I will avoid using aspirin for pain.
B. I will consume dairy products to increase my calcium intake.
C. I will drink 1.5 to 2 liters of fluid each day.
D. I will need to limit my intake of fiber.

Correct answer: A

Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.

5. What is the most important intervention for a patient with suspected DVT?

A. Administer anticoagulants
B. Monitor oxygen levels
C. Apply compression stockings
D. Encourage ambulation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Administering anticoagulants is crucial in the management of deep vein thrombosis (DVT) as it helps prevent the clot from growing larger or dislodging, potentially causing a life-threatening pulmonary embolism. While monitoring oxygen levels, applying compression stockings, and encouraging ambulation are important aspects of DVT management, administering anticoagulants is the most critical intervention to prevent further complications.