ATI RN Exit Exam

Correct Answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

Correct Answer: C

Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.

Correct Answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

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.

Correct Answer: C

Rationale: Asking about alcohol intake is crucial in assessing the client's risk factors and behaviors, especially in the context of a suicide threat. Understanding alcohol consumption patterns can help the nurse evaluate potential substance abuse issues and their impact on the client's mental health. Choices A, B, and D are less pertinent to the immediate concern of assessing suicide risk and conduct disorder symptoms.