NURSING MISC - MAIN VERSION PRIORITY ONE. QUESTIONS & ANSWERS. A+ RATED.
MAIN VERSION PRIORITY ONE
1. Missing
2. A nursing planning care for a
... [Show More] 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
Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short-term
(24 to 48 hr) around-the-clock administration of opioids is preferable to following a PRN
schedule.
ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO
cromolyn nebulizer stated on ATI.
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
Rationale Med Surg ATI PDF p457: s/s of fat embolism (dyspnea, increased RR,
decreased O2, headache, decreased LOC r/t low O2 levels, respiratory distress,
tachycardia, confusion, chest pain), Hip and pelvis fractures are common causes, can occur
after injury usually within 12-48 hrs
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)
Rationale https://medlineplus.gov/druginfo/meds/a601084.html : How to apply patch
Rationale ATI Skills Module Medication Administration: Topical medications include
lotions, creams, ointments, patches, and paste. Because topical medications are absorbed
by the skin, wear gloves when applying them to protect yourself against accidental
exposure
Shaving may cause skin irritation and change the absorption of the drug.
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
Rationale Med Surg ATI PDF p529: assess for improvement or worsening of
hypoglycemia. Repeat the administration of carbohydrates if not within normal limits, and
recheck blood glucose in 15 min. Risk for seizure & coma if condition worsens.
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 [Show Less]
