ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Fetal heart rate of 110/min
- B. 1+ pitting edema
- C. Blood pressure 138/80 mm Hg
- D. Urine output of 20 mL/hr
Correct answer: D
Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.
2. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include?
- A. Critical pathways have unlimited timeframes for completion.
- B. Critical pathways are designed to decrease health care costs.
- C. Patients follow the critical pathway if variances occur.
- D. Budgets are used to create the critical pathway.
Correct answer: B
Rationale: The correct answer is B. Critical pathways are structured, multi-disciplinary plans of care designed to decrease health care costs and improve outcomes by standardizing and streamlining processes. Choice A is incorrect because critical pathways have specific timeframes for completion. Choice C is incorrect as patients are expected to follow the critical pathway without deviations to achieve optimal outcomes. Choice D is incorrect because budgets do not create critical pathways; rather, they are based on clinical guidelines and best practices.
3. A nurse is caring for a client who has a prescription for furosemide. The nurse should monitor the client for which of the following electrolyte imbalances?
- A. Hypernatremia
- B. Hypokalemia
- C. Hypercalcemia
- D. Hypomagnesemia
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide, a loop diuretic, can cause potassium loss leading to hypokalemia. Monitoring potassium levels is crucial as low potassium can result in various complications like cardiac dysrhythmias. Choices A, C, and D are incorrect. Hypernatremia is high sodium levels, which are not typically associated with furosemide use. Hypercalcemia is elevated calcium levels and hypomagnesemia is low magnesium levels, which are not the primary electrolyte imbalances associated with furosemide.
4. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?
- A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
- B. Keep the infant's head covered with a cap.
- C. Ensure that the newborn wears a diaper.
- D. Apply lotion to the newborn every 4 hours.
Correct answer: C
Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.
5. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following sites should the healthcare provider select?
- A. Deltoid
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular injections in adults due to its large muscle mass and low risk of complications. The deltoid, although a common site for vaccines, has a smaller muscle mass and may not be suitable for all types of medications. The rectus femoris is a muscle in the thigh that is more commonly used for intramuscular injections in infants. The dorsogluteal site is no longer recommended due to its proximity to major nerves and blood vessels.
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