what are the nursing interventions for a patient with fluid volume overload
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What are the nursing interventions for a patient with fluid volume overload?

Correct answer: A

Rationale: The correct nursing intervention for a patient with fluid volume overload is to restrict fluid intake. This helps to prevent further fluid accumulation in the body. Monitoring intake and output (choice B) is important to assess the patient's fluid balance but is not a direct intervention to address fluid volume overload. Administering diuretics as prescribed (choice C) is a medical intervention that may be ordered by a healthcare provider but should not be assumed as a nursing intervention without a prescription. Elevating the head of the bed (choice D) is a measure commonly used for patients with respiratory distress or to prevent aspiration but is not a direct intervention for fluid volume overload.

2. A charge nurse is observing a newly licensed nurse apply sterile gloves. Which of the following actions by the newly licensed nurse demonstrates sterile technique?

Correct answer: A

Rationale: The correct answer is A. Putting the glove on the dominant hand first is a key step in maintaining sterile technique as it reduces the risk of contamination. By covering the dominant hand first, the nurse minimizes the risk of contaminating the other hand during the glove application process. Choices B, C, and D are incorrect. Choice B introduces the concept of a sterile gown, which is not relevant to the question about applying sterile gloves. Choice C is incorrect as putting sterile gloves last does not follow the correct sequence of steps in maintaining sterility. Choice D, while important, is not as critical as covering the dominant hand first when applying sterile gloves.

3. What is the nurse's responsibility when caring for a client with a chest tube?

Correct answer: A

Rationale: The correct answer is to check for air leaks in the tubing every 4 hours when caring for a client with a chest tube. This responsibility is crucial because it ensures proper chest tube function and helps prevent complications such as pneumothorax or hemothorax. Clamping the chest tube (Choice B) can lead to serious issues by causing a tension pneumothorax. Encouraging deep breathing and coughing (Choice C) is important for respiratory hygiene but is not directly related to chest tube care. Keeping the client in a high Fowler's position (Choice D) may be beneficial for some conditions but is not specific to chest tube management.

4. Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?

Correct answer: A

Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.

5. A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.

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