how should a nurse manage a patient with fluid overload

ATI LPN

PN ATI Comprehensive Predictor

1. How should a healthcare professional manage a patient with fluid overload?

A. Restrict fluids and administer diuretics
B. Increase fluid intake and provide oral diuretics
C. Administer antibiotics and monitor weight
D. Monitor weight and provide a low-sodium diet

Correct answer: A

Rationale: Corrected Question: When managing a patient with fluid overload, the appropriate approach involves restricting fluids and administering diuretics. This strategy helps remove excess fluid from the body and prevent complications associated with fluid overload. Choice B suggesting increasing fluid intake is incorrect as it would worsen the condition. Choice C, administering antibiotics, is unrelated to managing fluid overload. Choice D, monitoring weight and providing a low-sodium diet, is helpful but not as effective as fluid restriction and diuretics in managing fluid overload.

2. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

A. Administer scheduled doses of acetaminophen every 6 hr.
B. Monitor the child's cardiac status.
C. Administer antibiotics via intermittent IV bolus for 24 hr.
D. Provide stimulation with children of the same age in the playroom.

Correct answer: B

Rationale: Monitoring cardiac status is crucial during the acute phase of Kawasaki disease because of the potential for coronary artery complications. Acetaminophen may be used for fever management but is not the priority intervention. Antibiotics are not indicated as Kawasaki disease is not caused by a bacterial infection. Providing stimulation in the playroom is important for the child's emotional well-being but does not address the immediate physiological concern of cardiac monitoring.

3. What is the first step in assessing a patient with suspected stroke?

A. Check for facial droop
B. Assess speech clarity
C. Perform a neurological assessment
D. Call for emergency assistance

Correct answer: D

Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.

4. What is the first step in managing a client with delirium?

A. Administer sedative medication to calm the client
B. Identify any reversible causes of delirium
C. Limit environmental stimulation to reduce anxiety
D. Administer antipsychotic medication to control behavior

Correct answer: B

Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.

5. How should a healthcare professional assess a patient with suspected sepsis?

A. Monitor vital signs and administer antibiotics
B. Monitor for signs of infection and confusion
C. Monitor for fever and check oxygen saturation
D. Assess for confusion and administer fluids

Correct answer: A

Rationale: When assessing a patient with suspected sepsis, it is crucial to monitor vital signs like temperature, heart rate, respiratory rate, and blood pressure. Administering antibiotics promptly is also vital to treat the infection causing sepsis. This approach helps in preventing the progression of sepsis to severe stages and reduces the risk of complications. Choice B is incorrect because only monitoring signs of infection and confusion may delay necessary treatment with antibiotics. Choice C is incorrect as it focuses only on fever and oxygen saturation, missing other important vital signs. Choice D is incorrect because assessing for confusion alone is not sufficient, and administering fluids should be guided by the patient's fluid status rather than being an initial step in suspected sepsis assessment.