1. A nurse is caring for a client who has bipolar disorder and is experiencing acute
mania. The nurse obtained a verbal prescription for restraints.
... [Show More] Which of the following
should the actions the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client’s peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client’s condition every 15 minutes
2. A nursing planning care for a school-age child who is 4 hr postoperative
following perforated appendicitis. Which of the following actions should the nurse
include in the plan of care?
a. Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex
first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
3. A nurse is receiving change-of-shift report for a group of clients. Which of the
following clients should the nurse plan to assess first?
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower extremities
d. A client who has a hip fracture and a new onset of tachypnea
4. A nurse is preparing to apply a transdermal nicotine patch for a client.
Which of the following actions should the nurse tak e?
a. Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to
promote absorption; avoid oily or broken skin)
b. Wear gloves to apply the patch to the client’s skin
c. Apply the patch within 1 hr of removing it from the protective pouch (apply
immediately)
d. Remove the previous patch and place it in a tissue (fold patch in half with
sticky sides pressed together)
5. A nurse has just received change-of-shift report for four clients. Which of the
following clients should the nurse assess first?
a. A client who was just given a glass of orange juice for a low blood glucose level
b. A client who is schedule for a procedure in 1 hr (can wait)
c. A client who has 100 mL fluid remaining in his IV bag (can wait)
d. A client who received a pain medication 30 min ago for postoperative pain
6. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
a. A history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula
c. Sitting in a high-Fowler’s position during the feeding
d. A residual of 65 mL 1hr postprandial
7. A nurse is reviewing the laboratory results for a client who has Cushing’s
disease. The nurse should expect the client to have an increase in which of the
following laboratory values? a. Serum glucose level- increased
b. Serum calcium level-decreased
c. Lymphocyte count- decreased immune system.
d. Serum potassium level- decreased
. 8. A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate
after the client displaces toxicity. Which of the following actions should the nurse
take?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable
form of calcium gluconate available when administering magnesium sulfate by IV.
9. A charge nurse is teaching new staff members about factors that increase a client’s
risk to become violent. Which of the following risk factors should the nurse include as
the best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Previous violent behavior
d. A history of being in prison
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command
hallucinations, violent angry reactions with cognitive disorders).
Individual Assessment for Violence
10. A nurse is preparing to perform a sterile dressing change. Which of the
following actions should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from
the body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field →
2.5 cm (1-inch) border around any sterile drape or wrap that is considered
contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level;
should be ABOVE waist level
11. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime
12. A home health nurse is preparing for an initial visit with an older adult client
who lives alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
d. Arrange for client transportation to follow-up
appointments Rationale Priority: Assess first.
13. A nurse is assessing the remote memory of an older adult client who has mild
dementia. Which of the following questions should the nurse ask the client?
a. “Can you tell me who visited you today?”
b. “What high school did you graduate from
c. “Can you list your current medications?”
d. “What did you have for breakfast yesterday?”
14. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.
Which of the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 =
HYPOGLYCEMIC d. HbA1c level less than 7%
15. A nurse is caring for a client who is receiving phenytoin for management of
grand mal seizures and has a new prescription for isoniazid and rifampin. Which of
the following should the nurse conclude if the client develops ataxia and
incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client’s seizure disorder is no longer under
control c. The client is showing evidence of
phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
16. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty.
Which of the following manifestations requires immediate action by the nurse?
a. Increase in frequency of swallowing→ may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative)
Rationale “Requires immediate action” choose the worst possibility that could lead
to. ABC
17. A nurse is planning care for a preschool-age child who is in the acute phase
Kawasaki disease. Which of the following interventions should the nurse include
in the plan of care?
a. Give scheduled doses of acetaminophen
every 6 hr b. Monitor the child’s cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
18. A nurse is planning an educational program for high school students about
cigarette smoking. Which of the following potential consequences of smoking is most
likely to discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse
b. Smoking in adolescence increases the risk of developing lung cancer
later in life c. Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
19. A nurse is assessing a client who is prescribed spironolactone. Which of the
following laboratory values should the nurse monitor for this client?
a. Total bilirubin
b. Urine ketones
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
d. Platelet count
Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia
20. A nurse has agreed to serve as an interpreter for an older adult client who is
assigned to another nurse. Which of the following statements by the nurse indicates an
understanding of this role?
a. “I will let the client know that I am available as the interpreter.”
b. “I will receive a small fee for interpreting for this client.”
c. “I am glad I’m available today, but when I’m not, you can use a family member.”
d. “I will let the client know that an interpreter is unavailable during the night shift.”
21. A nurse is performing assessments on newborns in the nursery. Which of the
following findings should the nurse report to the provider?
a. A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal
b. A 16 hour old new newborn who has yet to pass meconium- you got 24
hours to pass stool
c, A 2 day old newborn who has a small amount of blood tinged vaginal discharge
d. A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
22. A nurse on an acute unit has received change of shift report for 4 clients
which of the following clients should the nurse assess first? Pain pallor
pulselessness paresthesia
a. A client who is 1 hr postoperative and has hypoactive bowel sounds
b. A client who has fractured left tibia and pallor in the affected extremity
c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
d. A client who has a elevated AST level following administration of azithromycin
23. A nurse is providing discharge instructions to a client who has a new prescription
for haloperidol which of the following adverse effects should the nurse instruct the
client to report to the provider?
a. Weight gain
b. Dry mouth→ anticholinergic effects
c. Sedation → s/s neuroleptic malignant syndrome??>> life threatening
d. Shuffling gait →A/E EPS: is an indication of parkinsonism and should be
reported to t
24. A nurse is planning discharge teaching about cord care for the parents of a newborn
b. Potato pancakes
c. Disorganized speech
c. Apply an orthotic to the clients foot
which [Show Less]