ATI RN
ATI Comprehensive Exit Exam
1. A nurse is caring for a client who is receiving furosemide. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?
- A. Serum sodium.
- B. Serum glucose.
- C. Serum potassium.
- D. Serum calcium.
Correct answer: C
Rationale: The correct answer is C: Serum potassium. Furosemide is a potassium-wasting diuretic, meaning it can lead to potassium loss in the body. Monitoring serum potassium levels is crucial to evaluate the effectiveness of furosemide and prevent hypokalemia. Options A, B, and D are incorrect because furosemide does not directly affect sodium, glucose, or calcium levels in the same way it impacts potassium levels.
2. A nurse is preparing to administer an IV bolus of 0.9% sodium chloride to a client who is dehydrated. Which of the following actions should the nurse take?
- A. Administer the solution slowly over 24 hours
- B. Assess the client's lung sounds before administration
- C. Change the IV tubing every 12 hours
- D. Flush the IV line with 2 mL of heparin every 4 hours
Correct answer: B
Rationale: The correct action for the nurse to take is to assess the client's lung sounds before administering IV fluids. This is crucial to identify any signs of fluid overload, such as crackles or wheezes. Administering the solution slowly over 24 hours (choice A) is not appropriate for an IV bolus, which is a rapid infusion. Changing the IV tubing every 12 hours (choice C) is a standard practice for preventing infection but is not directly related to administering an IV bolus. Flushing the IV line with heparin every 4 hours (choice D) is a maintenance practice to prevent clot formation in the line, not specifically related to administering an IV bolus.
3. A client who is at 28 weeks of gestation is being taught by a nurse about managing heartburn. Which of the following instructions should the nurse include?
- A. Eat small, frequent meals.
- B. Drink a glass of milk with each meal.
- C. Lie down after meals.
- D. Drink plenty of fluids with meals.
Correct answer: A
Rationale: The correct instruction for managing heartburn during pregnancy is to eat small, frequent meals. This helps prevent heartburn by reducing gastric distention. Option B, drinking a glass of milk with each meal, may exacerbate heartburn in some individuals due to its fat content. Option C, lying down after meals, can worsen heartburn as it allows stomach acid to flow back into the esophagus. Option D, drinking plenty of fluids with meals, can also contribute to heartburn by distending the stomach. Therefore, the best advice for managing heartburn during pregnancy is to eat small, frequent meals.
4. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water every day to prevent dryness.
- B. Wear cotton socks to keep your feet dry.
- C. Apply lotion between your toes after bathing.
- D. Cut your toenails in a rounded shape.
Correct answer: B
Rationale: The correct instruction the nurse should include is to 'Wear cotton socks to keep your feet dry.' This is essential in diabetes mellitus as moisture can lead to infections. Choice A is incorrect as soaking feet in warm water can actually cause dryness and skin breakdown, which is harmful in diabetes. Choice C is incorrect as applying lotion between the toes can create excess moisture, increasing the risk of fungal infections. Choice D is incorrect as cutting toenails in a rounded shape can lead to ingrown toenails; clients with diabetes should cut their nails straight across to prevent complications.
5. A nurse is caring for a client who has right-sided heart failure. Which of the following findings should the nurse expect?
- A. Peripheral edema.
- B. JVD.
- C. Crackles in the lungs.
- D. Hypotension.
Correct answer: B
Rationale: The correct answer is B: JVD. Jugular venous distention (JVD) is a common finding in right-sided heart failure due to fluid overload. This occurs because the right side of the heart is unable to effectively pump blood, leading to congestion and increased venous pressure, which is manifested as JVD. Choices A, C, and D are incorrect. Peripheral edema (choice A) is more commonly associated with left-sided heart failure. Crackles in the lungs (choice C) are indicative of pulmonary edema, often seen in left-sided heart failure. Hypotension (choice D) is not typically seen in right-sided heart failure, as it is more commonly associated with conditions like shock or severe dehydration.
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