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

ATI RN

ATI Exit Exam RN

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

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 diabetes insipidus. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: Increased urine output is a key finding in clients with diabetes insipidus due to a deficiency of antidiuretic hormone. Weight gain (choice A) is not expected in diabetes insipidus as it is a condition characterized by excessive thirst and urination leading to fluid loss. Bradycardia (choice C) and hyperactive bowel sounds (choice D) are not typically associated with diabetes insipidus.

3. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

Correct answer: C

Rationale: Respecting cultural preferences and providing client-centered care promotes trust.

4. A client is starting therapy with a statin medication. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming grapefruit juice when taking statin medication. Grapefruit juice can interfere with the metabolism of statins, leading to an increased risk of adverse effects. Taking the medication on an empty stomach (Choice A) or in the morning (Choice D) is not specifically necessary for statins. While increasing dietary fiber intake (Choice C) is generally beneficial for health, it is not a specific instruction related to taking statin medication.

5. Which lab value is most critical to monitor in a patient receiving digoxin?

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.

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