a nurse is preparing to administer an iv fluid bolus of 500 ml over 4 hours to a client who is dehydrated the nurse should set the iv pump to deliver
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A healthcare professional is preparing to administer an IV fluid bolus of 500 mL over 4 hours to a client who is dehydrated. The healthcare professional should set the IV pump to deliver how many mL/hr?

Correct answer: C

Rationale: Setting the IV pump to 125 mL/hr ensures the correct infusion rate for delivering 500 mL over 4 hours. To calculate the mL/hr rate, divide the total volume to be infused (500 mL) by the total time for infusion (4 hours): 500 mL / 4 hours = 125 mL/hr. Choice A (75 mL/hr) is too low and would result in an insufficient infusion rate, potentially delaying fluid resuscitation. Choice B (100 mL/hr) would also be too low and not deliver the fluid within the specified time frame. Choice D (150 mL/hr) is too high and would infuse the fluid too quickly, potentially causing fluid overload and complications.

2. A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.

3. A client has a nasogastric tube for gastric decompression. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.

4. A healthcare provider is performing a skin assessment for a client and observes several skin lesions. Which of the following findings is a priority to report to the provider?

Correct answer: D

Rationale: An irregularly shaped mole is a priority finding to report to the provider as it can be indicative of melanoma, a type of skin cancer. Melanoma is a serious condition that requires prompt evaluation and treatment. Raised nevus, macule, and vesicle are common skin findings that are typically benign and may not require immediate attention. Therefore, the irregularly shaped mole stands out as the priority due to its association with potential malignancy.

5. A client has a new prescription for furosemide. Which of the following statements should the nurse include in the teaching?

Correct answer: B

Rationale: The correct statement the nurse should include in the teaching for a client with a new prescription for furosemide is that the client should take the medication with food to prevent gastrointestinal upset. Furosemide is a loop diuretic that can cause gastrointestinal upset, so taking it with food can help reduce this side effect and improve medication tolerance. Choices A, C, and D are incorrect because furosemide does not increase potassium levels, decrease blood glucose levels, or require an increase in the intake of potassium-rich foods. Therefore, the most important teaching point for the client is to take furosemide with food.

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