ATI RN
ATI Exit Exam
1. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?
- A. Potassium 4.2 mEq/L
- B. Glucose 250 mg/dL
- C. Bicarbonate 20 mEq/L
- D. Sodium 135 mEq/L
Correct answer: B
Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.
2. A nurse is assessing a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following findings should the nurse report to the provider?
- A. Gastric residual of 200 mL
- B. Heart rate of 100/min
- C. Urinary output of 250 mL in 12 hr
- D. Blood glucose level of 180 mg/dL
Correct answer: D
Rationale: The correct answer is D. A blood glucose level of 180 mg/dL is higher than expected and should be reported to prevent hyperglycemia complications. High blood glucose levels can lead to hyperglycemia, causing various issues such as increased risk of infection and delayed wound healing. Choices A, B, and C are within normal limits for a client receiving continuous enteral feedings and do not require immediate reporting.
3. A healthcare professional is reviewing the laboratory findings of a client who has diabetes mellitus. Which of the following findings indicates a need to revise the client's plan of care?
- A. Serum sodium 144 mEq/L.
- B. HbA1c 10%.
- C. Random serum glucose 190 mg/dL.
- D. Creatinine 1.2 mg/dL.
Correct answer: C
Rationale: Elevated random serum glucose levels of 190 mg/dL indicate hyperglycemia and poor blood sugar control, requiring a revised plan of care. HbA1c levels above 7% also indicate long-term poor control of blood sugar. Serum sodium of 144 mEq/L and creatinine of 1.2 mg/dL are within normal ranges and do not directly indicate a need for a plan of care revision.
4. A client with heart failure is prescribed furosemide. What finding should the nurse report to the provider?
- A. Sodium 140 mEq/L
- B. Heart rate of 82/min
- C. Potassium level of 2.8 mEq/L
- D. Oxygen saturation 95%
Correct answer: C
Rationale: The correct answer is C. A potassium level of 2.8 mEq/L is low and should be reported to the provider. Furosemide can cause potassium depletion, leading to hypokalemia. Low potassium levels can result in cardiac dysrhythmias, which is a serious concern in clients with heart failure. Choices A, B, and D are within normal ranges and do not require immediate reporting. Sodium level of 140 mEq/L, heart rate of 82/min, and oxygen saturation of 95% are all acceptable findings.
5. A nurse is reviewing the medical records of a client with a history of depression who is experiencing a situational crisis. What should the nurse do first?
- A. Confirm the client's perception of the event.
- B. Notify the client's support system.
- C. Help the client identify personal strengths.
- D. Teach the client relaxation techniques.
Correct answer: A
Rationale: Confirming the client's perception of the event is crucial in understanding how they are interpreting the crisis situation. This helps the nurse gain insight into the client's perspective, emotions, and needs. By validating the client's perception, the nurse can establish trust and rapport, which are essential in providing effective support during a crisis. Notifying the client's support system (Choice B) may be important but should come after understanding the client's perspective. Helping the client identify personal strengths (Choice C) and teaching relaxation techniques (Choice D) are valuable interventions but should follow the initial step of confirming the client's perception to ensure individualized care.
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