ATI RN
ATI RN Comprehensive Exit Exam 2023
1. Which electrolyte imbalance is commonly seen in patients receiving furosemide?
- A. Hypokalemia
- B. Hypercalcemia
- C. Hyponatremia
- D. Hyperkalemia
Correct answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance necessitates close monitoring to prevent complications such as cardiac arrhythmias. Choices B, C, and D are incorrect. Hypercalcemia is not a common side effect of furosemide. Hyponatremia is more commonly associated with other medications like thiazide diuretics. Hyperkalemia is the opposite electrolyte imbalance and is not typically seen with furosemide use.
2. A client with a new colostomy requires care planning by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Change the ostomy pouch every 4 to 7 days.
- B. Empty the ostomy pouch when it is half full.
- C. Apply a skin barrier around the stoma.
- D. Cleanse the peristomal skin with alcohol.
Correct answer: A
Rationale: The correct answer is to change the ostomy pouch every 4 to 7 days. This practice helps prevent skin irritation and leakage by maintaining a clean and secure seal around the stoma. Option B is incorrect because it is more important to change the pouch regularly rather than emptying it when half full. Option C is incorrect as applying a skin barrier is typically done during the initial application of the pouch, not during regular changes. Option D is incorrect because alcohol can be too harsh for the peristomal skin and can cause irritation.
3. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?
- A. Fetal hypoxia
- B. Abruptio placentae
- C. Post maturity
- D. Head compression
Correct answer: D
Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.
4. A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Weigh the client weekly to monitor for fluid retention.
- B. Monitor the client's blood glucose level every 6 hours.
- C. Change the TPN tubing every 72 hours.
- D. Flush the TPN line with sterile water before and after administration.
Correct answer: B
Rationale: The correct answer is B: Monitor the client's blood glucose level every 6 hours. When a client is on TPN, it is crucial to monitor their blood glucose levels frequently to prevent complications such as hyperglycemia or hypoglycemia. Weighing the client weekly to monitor for fluid retention (choice A) is important but not as critical as monitoring blood glucose levels. Changing the TPN tubing every 72 hours (choice C) is important for infection control but does not directly relate to the client's metabolic status. Flushing the TPN line with sterile water before and after administration (choice D) is not a standard practice and may introduce contaminants into the TPN solution.
5. What is the primary nursing action for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Monitor vital signs
- D. Check oxygen saturation
Correct answer: A
Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.
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