ATI COMPREHENSIVE C
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Thenurse
obtained a verbal prescription for
... [Show More] restraints. Which of the following should the actions thenurse
take?
Request a renewal of the prescription every 8 hr.
Check the client’s peripheral pulse rate every 30 min
Obtain a prescription for restraint within 4 hr.
Document the client’s condition every 15 minutes
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 ofcare?
Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
Give cromolyn nebulizer solution every 6 hr (for asthma)
Apply a warm compress to the operative site every 4 hr
Administer analgesics on a scheduled basis for the first 24 hr
A nurse is receiving change-of-shift report for a group of clients. Which of the followingclients
should the nurse plan to assess first?
A client who has sinus arrhythmia and is receiving cardiac monitoring
A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
A client who has epidural analgesia and weakness in the lower extremities
A client who has a hip fracture and a new onset of tachypnea
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the
following actions should the nurse tak e?
Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote
absorption; avoid oily or broken skin)
Wear gloves to apply the patch to the client’s skin
Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
Remove the previous patch and place it in a tissue (fold patch in half with sticky sides
pressed together)
A nurse has just received change-of-shift report for four clients. Which of the followingclients
should the nurse assess first?
A client who was just given a glass of orange juice for a low blood glucose level
A client who is schedule for a procedure in 1 hr (can wait)
A client who has 100 mL fluid remaining in his IV bag (can wait)
A client who received a pain medication 30 min ago for postoperative pain
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which ofthe
following places the client at risk for aspiration?
A history of gastroesophageal reflux disease
Receiving a high osmolarity formula
Sitting in a high-Fowler’s position during the feeding
A residual of 65 mL 1hr postprandial
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
Serum calcium level-decreased
Lymphocyte count- decreased immune system.
Serum potassium level- decreased
. 8. A nurse is caring for a client who has severe preeclampsia and is receiving magnesiumsulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displacestoxicity.
Which of the following actions should the nurse take?
Position the client supine
Prepare an IV bolus of dextrose 5% in water
Administer methylergonovine IM
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.
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 predictorof future
violence?
Experiencing delusions
Male gender
Previous violent behavior
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
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?
Place the cap from the solution sterile side up on clean surface
Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body'sfirst
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.
Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; shouldbe
ABOVE waist level
A nurse is providing teaching to an older adult client about methods to promote nighttimesleep.
Which of the following instructions should the nurse include?
Eat a light snack before bedtime
Stay in bed at least 1 hr if unable to fall asleep
Take a 1 hr nap during the day
Perform exercises prior to bedtime
A home health nurse is preparing for an initial visit with an older adult client who livesalone.
Which of the following actions should the nurse take first?
Educate the client about current medical diagnosis
Refer the client to a meal delivery program
Identify environmental hazards in the home
Arrange for client transportation to follow-up appointments
Rationale Priority: Assess first.
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?
“Can you tell me who visited you today?”
“What high school did you graduate from
“Can you list your current medications?”
“What did you have for breakfast yesterday?”
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which ofthe
following goals should the nurse include in the teaching
HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
Blood glucose level greater than 200 mg/dL at bedtime
Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMICd.
HbA1c level less than 7%
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 shouldthe nurse
conclude if the client develops ataxia and incoordination?
The client is experiencing an adverse reaction to rifampin
The client’s seizure disorder is no longer under controlc.
The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
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?
Increase in frequency of swallowing→ may indicate bleeding
Moderate sanguineous drainage on the drip pad
Bruising to the face→ side effect
Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale
“Requires immediate action” choose the worst possibility that could lead to. ABC
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
Administer antibiotics via intermittent IV bolus for 24 hr
Provide stimulation with children of the same age in the playroom
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?
Use of tobacco might lead to alcohol and drug abuse
Smoking in adolescence increases the risk of developing lung cancer later in lifec.
Use of tobacco decreases the level of athletic ability
d. Smoking in adolescence increases the risk of lifelong addiction
A nurse is assessing a client who is prescribed spironolactone. Which of the following
laboratory values should the nurse monitor for this client?
Total bilirubin
Urine ketones
Serum potassium- diuretic that retains potassium= hyperkalemic risk
Platelet count
Rationale ATI PDF p: 146 Pharm Complications: hyperkalemia
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 thisrole?
“I will let the client know that I am available as the interpreter.”
“I will receive a small fee for interpreting for this client.”
“I am glad I’m available today, but when I’m not, you can use a family member.”
“I will let the client know that an interpreter is unavailable during the night shift.”
A nurse is performing assessments on newborns in the nursery. Which of the following
findings should the nurse report to the provider?
A two day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal
A 16 hour old new newborn who has yet to pass meconium- you got 24 hours to passstool
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
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 client who is 1 hr postoperative and has hypoactive bowel sounds
A client who has fractured left tibia and pallor in the affected extremity
A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
A client who has a elevated AST level following administration of azithromycin
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 tothe
provider?
Weight gain
Dry mouth→ anticholinergic effects
Sedation → s/s neuroleptic malignant syndrome??>> life threatening
Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported to t
A nurse is planning discharge teaching about cord care for the parents of a newborn which ofthe
following instructions should the nurse plan to include in the teaching? P . 177 ch 26
Clean the base of the cord with hydrogen peroxide daily- only with tub and sponge baths
The cord stump will fall off in 5 days- about 10 - 14 days
Contact the provider if the cord stump turns black
Keep the cord stump dry until it falls off
Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected
to turn black and dry.
A nurse is teaching dietary guidelines to a client who has celiac disease which of the
following food choices is appropriate for the client?
a. White flour tortillas
Wheat crackers
Canned barley soup
A nurse is working in acute care mental health facility is assessing a client who has
schizophrenia. Which of the following findings should the nurse expect?
All or nothing thinking
Euphoric mood
d. Hypochondriasis ( anxiety disorder)
A nurse is caring for a client who is immobile which of the following interventions is
appropriate to prevent contracture?
Align a trochanter wedge between the clients legs
Place a towel roll under the clients neck
d. Position a pillow under the client's knees
A public health nurse working in a rural area is developing a program to improve health forthe
local population. Which of the following actions should the nurse plan to take?
Provide anticipatory guidance classes to parents through public schools
Have a nurse from the outside the community provide health lectures at the countyhospital
Encourage rural residents to focus health spending on tertiary health interventions
Launch a media campaign to increase awareness about industrial pollution
A nurse in the emergency department is performing triage for multiple clients following a
disaster in the community. To which of the following types of injuries should the nurse assign
the highest priority?
Below the knee amputation → ESI Level 1
10cm (4 in) laceration → ESI Level 4
Fractured tibia → ESI Level 2; if pelvis, femur, or hip and other extremity dislocationthen level
1.
95% full thickness body burn →
A nurse is preparing a change of shift report for an adult female client who is postoperative.
Which of the following client information should the nurse include in the report?
CONFIRMED
a. Hgb 12.8 g/dl - 12- 16
Potassium 4.2 meq/l 3.5 - 5.0 meq
RBC 4.4 million/mm3
Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding
A nurse is admitting a client who has anorexia nervosa. Which of the following is an
expected finding?
Iron 90 mcg/dl
Prealbumin 10 mcg/dl (normal: 16-40)
Serum creatinine 0.8 mg/dl
b. Potato pancakes
c. Disorganized speech
c. Apply an orthotic to the clients foot
Calcium 9.5 mg/dl
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse
(LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift.Which
of the following client assignments should the nurse delegate to the LPN?
A client who has fractured a femur yesterday and is expecting SOB
A client who sustained a concussion and has unequal pupils
A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs [Show Less]