ATI RN
ATI RN Exit Exam
1. Which of the following is the most concerning electrolyte imbalance for a patient on furosemide?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct answer: A
Rationale: The correct answer is Hypokalemia. Furosemide, a loop diuretic, can lead to potassium depletion in the body, causing hypokalemia. This is a significant concern as low potassium levels can result in cardiac arrhythmias and other serious complications. Hyperkalemia (Choice B) is unlikely to occur as a result of furosemide use. Hyponatremia (Choice C) is more commonly associated with thiazide diuretics. Hypercalcemia (Choice D) is not typically linked to furosemide use.
2. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?
- A. Change the TPN tubing every 72 hours.
- B. Monitor the client's blood glucose every 4 hours.
- C. Monitor the client's urine output every 8 hours.
- D. Use sterile technique when changing the central line dressing.
Correct answer: D
Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.
3. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 90 seconds with a duration of 90 seconds. Which of the following actions should the nurse take?
- A. Increase oxytocin infusion.
- B. Decrease oxytocin infusion.
- C. Maintain oxytocin infusion.
- D. Discontinue oxytocin infusion.
Correct answer: D
Rationale: The correct action for the nurse to take in this scenario is to discontinue the oxytocin infusion. With contractions occurring every 90 seconds with a duration of 90 seconds, the contractions are too frequent and prolonged, which can lead to uterine rupture or fetal distress. Increasing or maintaining the oxytocin infusion would exacerbate the situation, potentially causing harm to the mother and fetus. Decreasing the oxytocin infusion might not be sufficient to address the issue, making discontinuation the most appropriate action to ensure the safety of both the client and the baby.
4. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?
- A. Request a renewal of the prescription every 8 hours.
- B. Check the client's peripheral pulse every 30 minutes.
- C. Obtain a prescription for restraints within 4 hours.
- D. Document the client's condition every 15 minutes.
Correct answer: D
Rationale: In the scenario presented, the correct action for the nurse to take when caring for a client with a verbal prescription for restraints due to acute mania is to document the client's condition every 15 minutes. Documenting at regular intervals is essential to monitor the client's well-being, assess the effects of the restraints, and ensure the client's safety. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse every 30 minutes (Choice B) is important but not as crucial as documenting the overall condition. Obtaining a prescription for restraints within 4 hours (Choice C) is not the immediate action needed when a verbal prescription is already obtained.
5. Which lab value is critical to monitor in patients receiving warfarin therapy?
- A. Monitor INR
- B. Monitor potassium levels
- C. Monitor platelet count
- D. Monitor sodium levels
Correct answer: A
Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial to monitor in patients receiving warfarin therapy. INR measures the blood's ability to clot and is used to ensure that patients are within the therapeutic range for warfarin therapy. This is important to prevent both clotting disorders and bleeding complications. Monitoring potassium levels (choice B) is not directly related to warfarin therapy. Platelet count (choice C) and sodium levels (choice D) are important parameters but are not as critical to monitor specifically for patients on warfarin therapy.
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