ATI RN Exit Exam

Correct Answer: C

Rationale: The presence of small blood clots in the urine is an expected finding after a TURP due to the surgical manipulation of the prostate bed and the bladder. However, larger clots can indicate excessive bleeding and should be reported promptly. Urine output of 30 mL/hr is within the expected range for post-TURP clients, indicating adequate kidney perfusion. Pink-tinged urine is also normal after a TURP due to minor bleeding from the surgical site. A blood pressure of 114/78 mm Hg is within normal limits and does not require immediate reporting.

Correct Answer: C

Rationale: When a patient is receiving IV potassium, it is crucial to monitor the IV site. Potassium can be irritating to the veins and may cause phlebitis or infiltration. Monitoring the IV site allows early detection of any potential complications. Checking urine output (Choice A) is important to assess kidney function but is not directly related to monitoring IV potassium. Blood pressure (Choice B) and respiratory rate (Choice D) are essential vital signs to monitor in general patient care but are not specific to monitoring IV potassium administration.

Correct Answer: B

Rationale: Placing the client in a private room is the appropriate infection control measure for C. difficile to prevent the spread of infection. While wearing a face shield may be necessary for procedures that generate splashes or sprays, it is not the primary precaution for C. difficile. Negative pressure rooms are typically used for airborne infections, not for C. difficile. Using an alcohol-based hand rub is important for hand hygiene but is not specific to managing C. difficile infection.

Correct Answer: A

Rationale: The correct answer is A: Crackles in the lung bases. In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, suggesting worsening respiratory status. This finding should be reported to the provider for further evaluation and management. Choice B, an oxygen saturation of 95%, is within the normal range and does not require immediate reporting. Choice C, a heart rate of 88/min, is also within normal limits and does not indicate an urgent need for intervention. Choice D, a frequent productive cough, is a common symptom in pneumonia and may not require immediate reporting unless it is severe or worsening. Therefore, crackles in the lung bases are the most concerning finding that warrants prompt attention.

Correct Answer: B

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods when taking furosemide. Furosemide is a loop diuretic that can cause potassium loss, so consuming potassium-rich foods like bananas and oranges can help maintain adequate potassium levels. Choice A is incorrect because there is no need to avoid consuming dairy products. Choice C is incorrect because while fluid intake may need to be monitored, the general instruction is not to limit fluids to prevent dehydration. Choice D is incorrect because furosemide is usually best taken during the day to avoid disrupting sleep with frequent urination.