ATI RN
ATI Comprehensive Exit Exam
1. A client receiving morphine via patient-controlled analgesia (PCA) should have naloxone administered if their respiratory rate is below 10/min. What action should the nurse take?
- A. Monitor the client's blood pressure every 4 hours.
- B. Ask the client to rate their pain every 2 hours.
- C. Administer naloxone if the client's respiratory rate is below 10/min.
- D. Evaluate the client's use of the PCA every 4 hours.
Correct answer: C
Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.
2. A client has a new prescription for furosemide. Which of the following instructions should the nurse include?
- A. Take this medication with a full glass of water in the morning.
- B. Monitor your blood pressure daily while taking this medication.
- C. Take this medication at bedtime to prevent nocturia.
- D. Avoid taking this medication with food.
Correct answer: A
Rationale: The correct answer is to instruct the client to take furosemide with a full glass of water in the morning. Furosemide is a diuretic that can cause increased urination, so it is best taken earlier in the day to avoid disrupting sleep with nocturia. Choice B is not the priority instruction for furosemide. Choice C is incorrect as taking furosemide at bedtime can lead to nocturia, which is undesirable. Choice D is incorrect because furosemide can be taken with or without food.
3. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?
- A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
- B. Avoid soaking your feet in warm water daily to prevent dry skin.
- C. Trim your toenails straight across to prevent injury.
- D. Do not apply a heating pad to your feet if they feel cold.
Correct answer: C
Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.
4. A client is receiving furosemide for heart failure. Which of the following findings should the nurse report to the provider?
- A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
- B. Heart rate of 68/min.
- C. Potassium level of 3.8 mEq/L.
- D. Urine output of 60 mL/hr.
Correct answer: B
Rationale: The correct answer is B. A heart rate of 68/min is lower than expected and should be reported as it may indicate digoxin toxicity. Choices A, C, and D are within normal limits for a client receiving furosemide for heart failure and do not require immediate reporting. Weight loss may be expected due to diuretic therapy, a potassium level of 3.8 mEq/L is within the normal range, and a urine output of 60 mL/hr indicates adequate renal perfusion.
5. A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will avoid eating foods that contain tyramine.''
- B. ''I should increase my salt intake while taking this medication.''
- C. ''I should drink at least 2 liters of water each day while taking this medication.''
- D. ''I should avoid consuming caffeinated beverages while taking this medication.''
Correct answer: C
Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.
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