Nursing 360 Adult health Exam 1 Review Answer Key with complete solution with rationale 2023 (All answers are correct)

NURSING 360 Adult health Exam 1 Review Answer Key with complete solution with rationale 1. A client develops moist crackles and dyspnea while receiving an IV infusion at 150 mL/hr. Based on this information, which intervention should be the nurse’s first priority? a. Elevate the head of the bed to 90 degrees b. Encourage the client to turn, cough, and deep-breathe. c. Administer oxygen via nasal cannula at 2 L/min. d. Stop the infusion and notify the health-care provider. Rationale: The nurse’s first priority in this situation is to stop the infusion and notify the healthcare provider. Moist crackles and dyspnea are classic signs of fluid overload. IV fluids should be stopped to prevent further FVE and the health-care provider should be notified. 2. An elderly client presents to a clinic complaining of fatigue, shortness of breath, and restlessness. A nurse assesses the client, suspecting fluid volume excess (FVE). Which manifestations identified during the assessment should the nurse associate the FVE? Select all that apply. a. Polyuria b. Weak pulse c. Weight gain d. Crackles in lungs e. Increased respirations Rationale: The nurse should associate weight gain, crackles in lungs, and increased respirations with FVE. Other signs of FVE include oliguria (not polyuria), bounding pulse (not weak pulse), increase blood pressure, and venous distention. 3. A nurse is educating a client regarding a prescribed loop diuretic. Which instructions should the nurse include in the client’s education? Select all that apply. a. Take a double dose if one dose is missed, to avoid edema. b. Change positions slowly to avoid orthostatic hypotension. c. Notify the health-care provider of a weight gain of more than 2 lb in 1 day. d. Follow a low-potassium diet. e. Use sunscreen and protective clothing when outdoors. Rationale: The nurse should instruct the client to change position slowly to minimize orthostatic hypotension. The nurse should instruct the client to notify the health care professional of weight gain greater than 2 lb in 1 day or 3 lb in 1 week because rapid weight gain is the best indication