ATI COMPREHENSIVE C
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Thenurse
obtained a verbal prescription
... [Show More] for 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?
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.
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 = HYPOGLYCEMIC
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.
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 [Show Less]