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 chronic kidney disease and a serum potassium level of 6.5 mEq/L. Which of the following actions should the nurse take?

A. Administer sodium bicarbonate
B. Administer sodium polystyrene sulfonate
C. Administer calcium gluconate
D. Administer calcium carbonate

Correct answer: B

Rationale: The correct action for the nurse to take is to administer sodium polystyrene sulfonate. This medication promotes potassium excretion and helps lower serum potassium levels in clients with hyperkalemia, which is indicated by a high potassium level. Sodium bicarbonate (choice A) is not used to treat hyperkalemia. Calcium gluconate (choice C) and calcium carbonate (choice D) are used to manage hyperkalemia by stabilizing cell membranes but are not the initial treatment choice for lowering potassium levels.

3. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?

A. Do you understand that the voices are not real?
B. Why do you think the voices are talking to you?
C. Have you tried going to a private place when this occurs?
D. What helps you ignore what you are hearing?

Correct answer: D

Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.

4. A nurse is teaching a client who has a new prescription for alendronate. Which of the following client statements indicates an understanding of the teaching?

A. I should take this medication at bedtime to prevent drowsiness.
B. I should take this medication with a full glass of water before breakfast.
C. I should avoid taking this medication with dairy products.
D. I should remain upright for at least 30 minutes after taking this medication.

Correct answer: B

Rationale: The correct answer is B. Alendronate should be taken with a full glass of water before breakfast to prevent esophageal irritation and improve absorption. Choice A is incorrect as alendronate is not associated with causing drowsiness. Choice C is incorrect because alendronate can be taken with or without food, so avoiding dairy products is not necessary. Choice D is incorrect as the recommended time to remain upright after taking alendronate is 30 minutes to 1 hour, not just 30 minutes.

5. A client expresses fear of surgery. Which response should the nurse make?

A. Explain the risks of the surgery in detail.
B. Tell the client that many clients feel anxious before surgery.
C. Reassure the client that the surgical team is highly experienced.
D. Acknowledge the client's feelings and ask open-ended questions.

Correct answer: D

Rationale: When a client expresses fear of surgery, it is essential for the nurse to acknowledge their feelings and ask open-ended questions. This response shows empathy, validates the client's emotions, and encourages them to express their concerns further. Explaining the risks of the surgery in detail (Choice A) may increase the client's anxiety. Simply stating that many clients feel anxious before surgery (Choice B) does not address the client's specific fears. While reassuring the client about the surgical team's experience (Choice C) is important, it may not directly alleviate the client's fear.