what is the priority intervention for a patient with fluid overload
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. What is the priority intervention for a patient with fluid overload?

Correct answer: A

Rationale: The correct answer is to administer diuretics. Diuretics help reduce excess fluid in cases of fluid overload, making it the priority intervention. Administering additional IV fluids (choice B) would exacerbate the problem by adding more fluid. Providing oral fluids (choice C) is not the priority as the excess fluid needs to be removed first. Chest physiotherapy (choice D) is not the primary intervention for fluid overload.

2. A client reports intimate partner violence to a nurse. What is the nurse's priority action?

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.

3. Which lab value is most critical to monitor in a patient receiving digoxin?

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.

4. A client who has a positive stool culture for Clostridium difficile should be placed in which type of room for infection control purposes?

Correct answer: B

Rationale: Placing the client in a private room is the appropriate infection control measure for C. difficile to prevent the spread of infection. While wearing a face shield may be necessary for procedures that generate splashes or sprays, it is not the primary precaution for C. difficile. Negative pressure rooms are typically used for airborne infections, not for C. difficile. Using an alcohol-based hand rub is important for hand hygiene but is not specific to managing C. difficile infection.

5. A nurse is preparing to teach a client about the use of a peak flow meter. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for using a peak flow meter is to place the mouthpiece in your mouth and blow out as quickly as you can. This action helps measure the peak expiratory flow of the client. Choice B is incorrect because exhaling slowly does not provide an accurate peak flow reading. Choice C is incorrect as taking a slow deep breath before blowing interferes with obtaining an accurate measurement. Choice D is incorrect as blowing at a steady rate for 3 seconds may not reflect the peak expiratory flow accurately.

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