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 caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?

A. Encourage deep breathing exercises
B. Maintain the client in a supine position
C. Apply a sequential compression device
D. Massage the client's legs

Correct answer: C

Rationale: The correct answer is C: Apply a sequential compression device. Applying a sequential compression device promotes venous return by assisting with blood circulation in the lower extremities, reducing the risk of blood clots. Encouraging deep breathing exercises can help with lung expansion but does not directly promote venous return. Maintaining the client in a supine position may not be ideal for promoting venous return if the client is unable to move. Massaging the client's legs may be contraindicated postoperatively due to the risk of dislodging a clot or causing trauma to the surgical site.

3. A client needs a 24-hour urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

A. I had a bowel movement, but I was able to save the urine.
B. I have a specimen in the bathroom from about 30 minutes ago.
C. I flushed what I urinated at 7 am and have saved the rest since.
D. I drink a lot, so I will fill up the bottle and complete the test quickly.

Correct answer: C

Rationale: Choice C is correct because it demonstrates the client's understanding of the procedure, which involves discarding the first urine of the day at the specified time and then saving all subsequent urine for the next 24 hours. Choices A, B, and D do not reflect an understanding of the correct procedure. Choice A is incorrect because bowel movements are not part of a 24-hour urine collection. Choice B is incorrect as it does not specify discarding the first urine. Choice D is incorrect as it mentions filling up the bottle quickly, which is not the correct way to collect a 24-hour urine sample.

4. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?

A. Prohibit smoking near oxygen equipment
B. Ensure the client uses non-flammable bedding
C. Ensure oxygen tanks are stored upright
D. Keep the oxygen equipment at least 6 feet away from heat sources

Correct answer: D

Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.

5. What is the nurse's role in preoperative patient care?

A. Provide patient education and ensure NPO status
B. Ensure that informed consent is obtained
C. Obtain the patient's health history
D. Confirm the patient's surgical site

Correct answer: A

Rationale: The nurse plays a crucial role in preoperative patient care by providing education and ensuring NPO (nothing by mouth) status. This helps prepare the patient for surgery by ensuring they understand the procedure, what to expect, and also by following necessary preoperative fasting guidelines. While obtaining the patient's health history (choice C) is important for overall patient assessment, it is typically done during the preoperative assessment but does not specifically pertain to the nurse's role. Ensuring informed consent (choice B) is primarily the responsibility of the healthcare provider performing the procedure. Confirming the patient's surgical site (choice D) is usually the responsibility of the surgical team and is done immediately before the surgery to prevent errors.