ATI RN
ATI Exit Exam
1. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 16/min.
- B. Blood pressure 118/78 mm Hg.
- C. Urinary output of 30 mL/hr.
- D. Absent deep-tendon reflexes.
Correct answer: D
Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.
2. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse identify as a manifestation of digoxin toxicity?
- A. Constipation.
- B. Tachycardia.
- C. Visual disturbances.
- D. Hypertension.
Correct answer: C
Rationale: Visual disturbances, such as blurred or yellow vision, are common signs of digoxin toxicity. While constipation (Choice A) is not typically associated with digoxin toxicity, tachycardia (Choice B) and hypertension (Choice D) are not characteristic manifestations of digoxin toxicity. Therefore, the correct answer is visual disturbances (Choice C).
3. A client with type 1 diabetes mellitus is receiving foot care education from a nurse. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Apply lotion to your feet after bathing.
- D. Trim toenails straight across.
Correct answer: D
Rationale: The correct answer is D: 'Trim toenails straight across.' In clients with diabetes, trimming toenails straight across is important to prevent ingrown toenails, reducing the risk of infections. Soaking feet in warm water daily (choice A) can lead to dry skin and potentially cause skin breakdown in diabetic clients. While wearing cotton socks (choice B) is beneficial for good foot hygiene, it is not as crucial as trimming toenails correctly. Applying lotion to feet after bathing (choice C) is helpful for moisturizing the skin, but the emphasis should be on nail care to prevent complications like ingrown toenails.
4. A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?
- A. Hypnosis focuses on biofeedback as a relaxation technique
- B. Hypnosis promotes increased control of pain perception during contractions
- C. Hypnosis uses therapeutic touch to reduce anxiety during labor
- D. Hypnosis provides instruction to minimize pain
Correct answer: B
Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.
5. Which electrolyte imbalance is commonly associated with patients on furosemide?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss in the body, resulting in hypokalemia. This electrolyte imbalance is commonly associated with furosemide use due to its mechanism of action in the kidneys. Hyponatremia (choice B) is not typically associated with furosemide. Hyperkalemia (choice C) and hypercalcemia (choice D) are not common electrolyte imbalances seen with furosemide use.
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