how should a nurse manage fluid overload in a patient with heart failure
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. How should fluid overload in a patient with heart failure be managed?

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

2. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct answer is to place the client in a negative pressure room. This action is necessary to prevent the spread of tuberculosis, as it is transmitted via airborne particles. Placing the client in droplet isolation (choice C) is not sufficient for tuberculosis, as it requires airborne precautions. Wearing a surgical mask (choice B) when entering the client's room may not provide adequate protection against airborne transmission. Placing a surgical mask on the client when transporting them (choice D) does not address the need for environmental controls to contain infectious particles.

3. A nurse is caring for a client who has pneumonia. Which of the following manifestations should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Tachypnea. When caring for a client with pneumonia, the nurse should expect tachypnea, which is rapid breathing. This occurs due to decreased oxygenation and lung function. Bradycardia (A) is not typically associated with pneumonia; instead, tachycardia may be present. Hypertension (B) is not a common manifestation of pneumonia; instead, hypotension may occur due to sepsis. Hypothermia (D) is not a typical finding in pneumonia; fever or an elevated temperature is more common.

4. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Peripheral edema. In right-sided heart failure, the heart struggles to pump blood efficiently, leading to fluid backup in the body. This fluid retention commonly manifests as peripheral edema, causing swelling in the legs, ankles, and feet. Choices A, B, and D are incorrect. Weight loss is not typically associated with right-sided heart failure; bradycardia (slow heart rate) is more commonly seen in conditions like hypothyroidism or athletes, not specifically in right-sided heart failure; and a dry cough is more commonly associated with conditions like pneumonia or bronchitis, not typically with right-sided heart failure.

5. What is the initial action a healthcare provider should take when a patient presents with chest pain?

Correct answer: C

Rationale: The correct initial action when a patient presents with chest pain is to obtain an ECG. This helps assess the heart's electrical activity and determine the cause of chest pain. Administering aspirin or oxygen therapy may be necessary later based on the ECG findings, but obtaining an ECG is the priority to evaluate the cardiac status. Surgery preparation is not the initial action for chest pain and should only be considered after a thorough assessment.

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