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 receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A. A client who has sinus arrhythmia and is receiving monitoring.
B. A client who has a hip fracture and a new onset of tachypnea.
C. A client who has epidural analgesia and weakness in the lower extremities.
D. A client who has diabetes and a hemoglobin A1C of 6.8%.

Correct answer: B

Rationale: The correct answer is B because a new onset of tachypnea can indicate a respiratory complication, which requires immediate assessment. Sinus arrhythmia, epidural analgesia with weakness, and a hemoglobin A1C level of 6.8% in a client with diabetes do not pose immediate life-threatening concerns that require urgent assessment compared to the potential respiratory issues associated with tachypnea.

3. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A. Blood pressure of 110/70 mm Hg
B. Heart rate of 88/min
C. Respiratory rate of 20/min
D. Temperature of 37.3°C (99.1°F)

Correct answer: D

Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.

4. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD) who is prescribed home oxygen. Which of the following statements should the nurse make?

A. Check your oxygen equipment daily for proper function.
B. Increase the oxygen flow rate if you feel short of breath.
C. Store your oxygen tanks lying flat on the floor.
D. It is safe to smoke as long as you are more than 10 feet from the oxygen source.

Correct answer: A

Rationale: The correct statement for the nurse to make is to advise the client to check the oxygen equipment daily for proper function. This is crucial to ensure the client's home oxygen therapy is working effectively and safely. Choice B is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored upright, not lying flat. Choice D is incorrect and unsafe advice, as smoking near an oxygen source can lead to a fire hazard.

5. What is the best intervention for a patient experiencing hypoxia?

A. Administer oxygen
B. Reposition the patient
C. Provide humidified air
D. Provide chest physiotherapy

Correct answer: A

Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.