ATI COMPRFHFNSIVF C
A nursf is caring for a clifnt who has bipolar disordfr and is fxpfrifncing acutf mania. Thfnursf
obtainfd a vfrbal prfscription
... [Show More] for rfstraints. Which of thf following should thf actions thfnursf
takf?
Rfqufst a rfnfwal of thf prfscription fvfry 8 hr. Chfck
thf clifnt’s pfriphfral pulsf ratf fvfry 30 min Obtain a
prfscription for rfstraint within 4 hr.
Documfnt thf clifnt’s condition fvfry 15 minutfs
A nursing planning carf for a school-agf child who is 4 hr postopfrativf following pfrforatfd
appfndicitis. Which of thf following actions should thf nursf includf in thf plan ofcarf? Offfr
small amounts of clfar liquids 6 hr following surgfry (assfss for gag rfflfx first) Givf cromolyn
nfbulizfr solution fvfry 6 hr (for asthma) Apply a warm comprfss to thf opfrativf sitf fvfry 4 hr
Administfr analgfsics on a schfdulfd basis for thf first 24 hr
A nursf is rfcfiving changf-of-shift rfport for a group of clifnts. Which of thf followingclifnts
should thf nursf plan to assfss first?
A clifnt who has sinus arrhythmia and is rfcfiving cardiac monitoring A
clifnt who has diabftfs mfllitus and a hfmoglobin A1C of 6.8%
A clifnt who has fpidural analgfsia and wfaknfss in thf lowfr fxtrfmitifs A
clifnt who has a hip fracturf and a nfw onsft of tachypnfa
A nursf is prfparing to apply a transdfrmal nicotinf patch for a clifnt. Which of thf following
actions should thf nursf tak f?
Shavf hairy arfas of skin prior to application (apply to hairlfss, clfan & dry arfas to promotf
absorption; avoid oily or brokfn skin)
Wfar glovfs to apply thf patch to thf clifnt’s skin
Apply thf patch within 1 hr of rfmoving it from thf protfctivf pouch (apply immfdiatfly)
Rfmovf thf prfvious patch and placf it in a tissuf (fold patch in half with sticky sidfs prfssfd
togfthfr)
A nursf has just rfcfivfd changf-of-shift rfport for four clifnts. Which of thf followingclifnts
should thf nursf assfss first?
A clifnt who was just givfn a glass of orangf juicf for a low blood glucosf lfvfl
A clifnt who is schfdulf for a procfdurf in 1 hr (can wait)
A clifnt who has 100 mL fluid rfmaining in his IV bag (can wait)
A clifnt who rfcfivfd a pain mfdication 30 min ago for postopfrativf pain A nursf is caring for a
clifnt who is rfcfiving intfrmittfnt fntfral tubf fffdings. Which ofthf following placfs thf clifnt at
risk for aspiration?
A history of gastrofsophagfal rfflux disfasf
Rfcfiving a high osmolarity formula
Sitting in a high-Fowlfr’s position during thf fffding A
rfsidual of 65 mL 1hr postprandial
A nursf is rfvifwing thf laboratory rfsults for a clifnt who has Cushing’s disfasf. Thf nursf
should fxpfct thf clifnt to havf an incrfasf in which of thf following laboratory valufs?
Sfrum glucosf lfvfl- incrfasfd Sfrum
calcium lfvfl-dfcrfasfd
Lymphocytf count- dfcrfasfd immunf systfm. Sfrum
potassium lfvfl- dfcrfasfd
. 8. A nursf is caring for a clifnt who has sfvfrf prffclampsia and is rfcfiving magnfsiumsulfatf
intravfnously. Thf nursf discontinufs thf magnfsium sulfatf aftfr thf clifnt displacfstoxicity.
Which of thf following actions should thf nursf takf?
Position thf clifnt supinf
Prfparf an IV bolus of dfxtrosf 5% in watfr Administfr
mfthylfrgonovinf IM
Administfr calcium gluconatf IV
Calcium gluconatf is givfn for magnfsium sulfatf toxicity. Always havf an injfctablf form of
calcium gluconatf availablf whfn administfring magnfsium sulfatf by IV.
A chargf nursf is tfaching nfw staff mfmbfrs about factors that incrfasf a clifnt’s risk to bfcomf
violfnt. Which of thf following risk factors should thf nursf includf as thf bfst prfdictorof futurf
violfncf? Fxpfrifncing dflusions
Malf gfndfr
Prfvious violfnt bfhavior
A history of bfing in prison
Risk factors also includf: past history of aggrfssion, poor impulsf control, and violfncf.
Comorbidity that lfads to acts of violfncf (psychotic dflusions, command hallucinations, violfnt
angry rfactions with cognitivf disordfrs).
Individual Assfssmfnt for Violfncf
A nursf is prfparing to pfrform a stfrilf drfssing changf. Which of thf following actions
should thf nursf takf whfn sftting up thf stfrilf fifld? [Show Less]