ATI RN
ATI Exit Exam 180 Questions Quizlet
1. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should the nurse report to the provider?
- A. Potassium 4.0 mEq/L
- B. Calcium 9.5 mg/dL
- C. Heart rate of 60/min
- D. Sodium 140 mEq/L
Correct answer: C
Rationale: The correct answer is C: Heart rate of 60/min. A heart rate of 60/min is borderline bradycardia, which can be a sign of digoxin toxicity. Digoxin can cause bradycardia, so any further decrease in heart rate should be reported promptly to the healthcare provider. Choices A, B, and D are within the normal range and not specifically related to potential digoxin toxicity, so they do not require immediate reporting.
2. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. White blood cell count of 9,000/mm3
- C. Temperature of 37.8°C (100°F)
- D. Blood pressure of 118/78 mm Hg
Correct answer: C
Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.
3. A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?
- A. Peripheral edema.
- B. Bradycardia.
- C. Jugular vein distention.
- D. Dependent edema.
Correct answer: C
Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.
4. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?
- A. Low back pain
- B. Dyspnea
- C. Hypotension
- D. Thready pulse
Correct answer: B
Rationale: The correct answer is B: Dyspnea. Dyspnea, or difficulty breathing, is a common sign of fluid overload in a client receiving packed RBCs. When fluid accumulates in the lungs due to overload, it can lead to respiratory distress. This finding requires prompt intervention to prevent further complications. Choices A, C, and D are incorrect: A) Low back pain is not typically associated with fluid overload; C) Hypotension refers to low blood pressure and is not a typical finding in fluid overload; D) Thready pulse may indicate poor perfusion but is not a direct indicator of fluid overload.
5. A nurse is caring for a client who has a prescription for a high-protein diet. Which of the following foods should the nurse recommend?
- A. Almonds
- B. Cheddar cheese
- C. Chicken breast
- D. Pasta
Correct answer: C
Rationale: Chicken breast is an excellent choice for a high-protein diet as it is a lean source of protein. Almonds, while a good source of protein, also contain high amounts of fat. Cheddar cheese is high in protein but also high in saturated fat. Pasta is not a significant source of protein compared to chicken breast.
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