ATI RN
ATI RN Comprehensive Exit Exam
1. Which electrolyte imbalance is commonly seen in patients taking 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 urine, resulting in hypokalemia. This electrolyte imbalance is commonly seen in patients taking furosemide and requires close monitoring. Choices B, C, and D are incorrect because furosemide does not typically cause hyponatremia, hyperkalemia, or hypercalcemia as frequently as it causes hypokalemia.
2. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30 degrees.
- B. Check gastric residual volumes every 4 hours.
- C. Administer the feeding at room temperature.
- D. Flush the feeding tube with 20 mL of water every 8 hours.
Correct answer: B
Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.
3. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
- A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
- B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
- C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
- D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.
Correct answer: C
Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.
4. Which electrolyte imbalance is most concerning for a patient on furosemide?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypercalcemia
Correct answer: A
Rationale: The correct answer is hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss through increased urinary excretion, making hypokalemia the most concerning electrolyte imbalance. Hyponatremia (Choice B) is not typically associated with furosemide use. Hyperkalemia (Choice C) is less likely due to furosemide's potassium-wasting effect. Hypercalcemia (Choice D) is not a common electrolyte imbalance seen with furosemide.
5. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Warm, dry skin
- C. Irritability
- D. Hyperventilation
Correct answer: C
Rationale: Irritability is a common finding in clients with hypoglycemia due to decreased glucose levels in the brain. Polyuria (excessive urination) is not typically associated with hypoglycemia, but rather with hyperglycemia. Warm, dry skin is not a typical finding in hypoglycemia; instead, the skin may be cool and clammy. Hyperventilation is not a common finding in hypoglycemia; instead, shallow breathing or difficulty breathing may occur.
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