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 client with chronic kidney disease is being taught by a nurse about managing protein intake. Which of the following instructions should the nurse include?
- A. You should increase your intake of high-protein foods.
- B. You should limit your intake of high-protein foods.
- C. You should avoid all protein sources to prevent further kidney damage.
- D. You should increase your intake of animal protein.
Correct answer: B
Rationale: The correct answer is B: 'You should limit your intake of high-protein foods.' Clients with chronic kidney disease should restrict their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Option A is incorrect as increasing intake of high-protein foods can exacerbate the condition. Option C is incorrect as avoiding all protein sources is not advisable, as some proteins are essential for overall health. Option D is incorrect as increasing the intake of animal protein can put more strain on the kidneys due to the metabolites produced during protein breakdown.
3. A nurse is caring for a client who is 36 weeks gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Proteinuria of 1+.
- B. Blood pressure 120/80 mm Hg.
- C. Respiratory rate of 18/min.
- D. Nonpitting ankle edema.
Correct answer: D
Rationale: Nonpitting ankle edema is a concerning sign of worsening preeclampsia due to fluid retention and should be reported immediately. Proteinuria of 1+ is a common finding in preeclampsia. A blood pressure of 120/80 mm Hg is within normal limits. A respiratory rate of 18/min is also within normal range. Therefore, choices A, B, and C are not as urgent as nonpitting ankle edema in this scenario.
4. A nurse in a mental health facility is caring for a client who is angry and throwing objects at staff members. Which of the following actions should the nurse take?
- A. Ask the client to identify what made them angry.
- B. Instruct the client to calm down.
- C. Place the client in seclusion.
- D. Encourage the client to attend group therapy.
Correct answer: C
Rationale: During a situation where a client is exhibiting violent behavior like throwing objects and posing a risk to themselves and others, the immediate priority is to ensure the safety of all involved. Placing the client in seclusion is a necessary intervention to prevent harm and allow for de-escalation. Asking the client to identify the trigger or instructing them to calm down may not be effective or safe in this escalated state. Encouraging the client to attend group therapy is not suitable when they are in an agitated and aggressive state that requires immediate intervention.
5. A client with deep vein thrombosis receiving heparin therapy needs monitoring. Which test should the nurse use to regulate the medication dosage?
- A. Prothrombin time (PT)
- B. International Normalized Ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Fibrinogen levels
Correct answer: C
Rationale: The correct answer is C: Activated partial thromboplastin time (aPTT). aPTT is specifically used to monitor and regulate heparin therapy as it assesses the intrinsic pathway of coagulation, which heparin affects. Options A and B, Prothrombin time (PT) and International Normalized Ratio (INR), are used to monitor warfarin therapy, not heparin. Option D, Fibrinogen levels, is not the primary test used to monitor heparin therapy.
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