what is the best way to assess for fluid overload in a patient with heart failure
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Nursing Elites

ATI RN

ATI RN Exit Exam Quizlet

1. What is the best way to assess for fluid overload in a patient with heart failure?

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

2. A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.

3. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?

Correct answer: B

Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures accurate readings. Placing the infant under a radiant warmer (Choice A) is not necessary for pulse oximetry monitoring. Heating the skin before placing the probe (Choice C) can potentially cause burns in infants. Placing a sensor on the index finger (Choice D) is not the standard practice for continuous pulse oximetry in infants.

4. Which medication is used to treat opioid overdose?

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the standard medication for reversing opioid overdose by blocking opioid receptors. Choice B, Epinephrine, is used to treat severe allergic reactions (anaphylaxis) and cardiac arrest, not opioid overdose. Choice C, Lidocaine, is a local anesthetic used for numbing purposes and managing certain types of arrhythmias, not for opioid overdose. Choice D, Atropine, is used to treat bradycardia, organophosphate poisoning, and nerve agent toxicity, not opioid overdose.

5. A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client who speaks a different language is to review the facility policy about the use of an interpreter. This ensures compliance with best practices for communication when using interpreters, maintaining accuracy and confidentiality. Requesting an interpreter of a different sex from the client (Choice A) is not relevant to effective communication. Asking a family member or friend to interpret (Choice B) can lead to misinterpretation or breach of confidentiality. Directing attention toward the interpreter (Choice C) is not as crucial as understanding the facility's policy on interpreter use.

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