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RN ATI CAPSTONE COMPREHENSIVE C.pdf
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● A nurse is caring for a client who has bipolar disorder and is
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experiencing acute mania. The nurse obtained a verbal prescription
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for restraints. Whichof the following should the actions the nurse
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take?
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A. Request a renewal of the prescription every 8 hr.
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B. Check the client’s peripheral pulse rate every 30 min
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C. Obtain a prescription for restraint within 4 hr.
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D. Document the client’s condition every 15 minutes
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● A nursing planning care for a school-age child who is 4 hr
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postoperative following perforated appendicitis. Which of the following
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actions should the nurse include in the plan of care?
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a. Offer small amounts of clear liquids 6 hr following surgery (assess for
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gag reflex first)
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b. Give cromolyn nebulizer solution every 6 hr (for asthma)
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c. Apply a warm compress to the operative site every 4 hr
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d. Administer analgesics on a scheduled basis for the first 24 hr
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● A nurse is receiving change-of-shift report for a group of clients.
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Which of the following clients should the nurse plan to assess first?
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a. A client who has sinus arrhythmia and is receiving cardiac monitoring
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b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
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c. A client who has epidural analgesia and weakness in the lower
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extremities
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d. A client who has a hip fracture and a new onset of tachypnea
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● A nurse is preparing to apply a transdermal nicotine patch for a
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client. Which of the following actions should the nurse tak e?
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a. Shave hairy areas of skin prior to application (apply to hairless, clean &
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dry areas to promote absorption; avoid oily or broken skin)
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b. Wear gloves to apply the patch to the client’s skin
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c. Apply the patch within 1 hr of removing it from the protective pouch
(apply immediately)
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d. Remove the previous patch and place it in a tissue (fold patch in
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half with sticky sides pressed together)
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● A nurse has just received change-of-shift report for four clients.
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Which of the following clients should the nurse assess first?
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a. A client who was just given a glass of orange juice for a low blood
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glucose level
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b. A client who is schedule for a procedure in 1 hr (can wait)
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c. A client who has 100 mL fluid remaining in his IV bag (can wait)
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d. A client who received a pain medication 30 min ago for postoperative
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pain
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● A nurse is caring for a client who is receiving intermittent enteral
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tube feedings. Which of the following places the client at risk for
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aspiration?
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a. A history of gastroesophageal reflux disease
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b. Receiving a high osmolarity formula
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c. Sitting in a high-Fowler’s position during the feeding
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d. A residual of 65 mL 1hr postprandial
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● A nurse is reviewing the laboratory results for a client who has
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Cushing’s disease. The nurse should expect the client to have an increase
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in which of the following laboratory values? a. Serum glucose level-
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increased
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b. Serum calcium level-decreased
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c. Lymphocyte count- decreased immune system.
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d. Serum potassium level- decreased
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. 8. A nurse is caring for a client who has severe preeclampsia and is
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receiving magnesium sulfate intravenously. The nurse discontinues the
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magnesium sulfate after the client displaces toxicity. Which of the
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following actions should the nurse take?
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a. Position the client supine
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b. Prepare an IV bolus of dextrose 5% in water
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c. Administer methylergonovine IM
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d. Administer calcium gluconate IV
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Calcium gluconate is given for magnesium sulfate toxicity. Always have an
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injectable form of calcium gluconate available when administering
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magnesium sulfate by IV.
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9. A charge nurse is teaching new staff members about factors that
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increase a client’s risk to become violent. Which of the following risk factors
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should the nurse include as the best predictor of future violence?
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a. Experiencing delusions
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b. Male gender
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c. Previous violent behavior
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d. A history of being in prison
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Risk factors also include: past history of aggression, poor impulse control,
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and violence. Comorbidity that leads to acts of violence (psychotic
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delusions, command hallucinations, violent angry reactions with cognitive
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disorders).
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Individual Assessment for Violence
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10. A nurse is preparing to perform a sterile dressing change. Which of
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the following actions should the nurse take when setting up the sterile
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field?
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a. Place the cap from the solution sterile side up on clean surface
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b. Open the outermost flap of the sterile kit toward the body→ flap
AWAY from the body's first
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Sp
tz
sh
ne
RN ATI CAPSTONE COMPREHENSIVE C.pdf
la
tz
sh
Sp
ne
la
tz
sh
Sp
ne
la
tz
sh
● A nurse is caring for a client who has bipolar disorder and is
Sp
ne
experiencing acute mania. The nurse obtained a verbal prescription
la
for restraints. Whichof the following should the actions the nurse
tz
sh
Sp
take?
ne
A. Request a renewal of the prescription every 8 hr.
la
tz
B. Check the client’s peripheral pulse rate every 30 min
sh
Sp
C. Obtain a prescription for restraint within 4 hr.
ne
la
D. Document the client’s condition every 15 minutes
tz
sh
● A nursing planning care for a school-age child who is 4 hr
Sp
ne
postoperative following perforated appendicitis. Which of the following
la
actions should the nurse include in the plan of care?
tz
sh
Sp
a. Offer small amounts of clear liquids 6 hr following surgery (assess for
ne
gag reflex first)
la
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
tz
sh
Sp
c. Apply a warm compress to the operative site every 4 hr
ne
la
d. Administer analgesics on a scheduled basis for the first 24 hr
tz
sh
● A nurse is receiving change-of-shift report for a group of clients.
Sp
ne
Which of the following clients should the nurse plan to assess first?
la
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
tz
sh
Sp
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
ne
c. A client who has epidural analgesia and weakness in the lower
la
tz
extremities
sh
Sp
d. A client who has a hip fracture and a new onset of tachypnea
ne
la
sh
● A nurse is preparing to apply a transdermal nicotine patch for a
Sp
client. Which of the following actions should the nurse tak e?
la
Sp
, ne
tz
sh
ne
a. Shave hairy areas of skin prior to application (apply to hairless, clean &
la
dry areas to promote absorption; avoid oily or broken skin)
tz
sh
Sp
b. Wear gloves to apply the patch to the client’s skin
ne
la
tz
sh
Sp
ne
la
tz
sh
Sp
ne
la
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sh
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ne
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, ne
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c. Apply the patch within 1 hr of removing it from the protective pouch
(apply immediately)
la
tz
sh
d. Remove the previous patch and place it in a tissue (fold patch in
Sp
ne
half with sticky sides pressed together)
la
● A nurse has just received change-of-shift report for four clients.
tz
sh
Sp
Which of the following clients should the nurse assess first?
ne
a. A client who was just given a glass of orange juice for a low blood
la
tz
glucose level
sh
Sp
ne
b. A client who is schedule for a procedure in 1 hr (can wait)
la
c. A client who has 100 mL fluid remaining in his IV bag (can wait)
tz
sh
d. A client who received a pain medication 30 min ago for postoperative
Sp
ne
pain
la
● A nurse is caring for a client who is receiving intermittent enteral
tz
sh
Sp
tube feedings. Which of the following places the client at risk for
ne
aspiration?
la
tz
a. A history of gastroesophageal reflux disease
sh
Sp
b. Receiving a high osmolarity formula
ne
la
c. Sitting in a high-Fowler’s position during the feeding
tz
d. A residual of 65 mL 1hr postprandial
sh
Sp
ne
● A nurse is reviewing the laboratory results for a client who has
la
Cushing’s disease. The nurse should expect the client to have an increase
tz
sh
Sp
in which of the following laboratory values? a. Serum glucose level-
ne
increased
la
tz
sh
Sp
ne
la
tz
sh
Sp
ne
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sh
Sp
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b. Serum calcium level-decreased
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c. Lymphocyte count- decreased immune system.
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sh
Sp
d. Serum potassium level- decreased
ne
. 8. A nurse is caring for a client who has severe preeclampsia and is
la
tz
receiving magnesium sulfate intravenously. The nurse discontinues the
sh
Sp
magnesium sulfate after the client displaces toxicity. Which of the
ne
la
following actions should the nurse take?
tz
sh
a. Position the client supine
Sp
ne
b. Prepare an IV bolus of dextrose 5% in water
la
c. Administer methylergonovine IM
tz
sh
Sp
d. Administer calcium gluconate IV
ne
Calcium gluconate is given for magnesium sulfate toxicity. Always have an
la
tz
injectable form of calcium gluconate available when administering
sh
Sp
magnesium sulfate by IV.
ne
la
tz
sh
9. A charge nurse is teaching new staff members about factors that
Sp
ne
increase a client’s risk to become violent. Which of the following risk factors
la
should the nurse include as the best predictor of future violence?
tz
sh
Sp
a. Experiencing delusions
ne
b. Male gender
la
c. Previous violent behavior
tz
sh
Sp
d. A history of being in prison
ne
Risk factors also include: past history of aggression, poor impulse control,
la
tz
and violence. Comorbidity that leads to acts of violence (psychotic
sh
Sp
delusions, command hallucinations, violent angry reactions with cognitive
ne
disorders).
la
tz
Individual Assessment for Violence
sh
Sp
ne
la
10. A nurse is preparing to perform a sterile dressing change. Which of
tz
sh
the following actions should the nurse take when setting up the sterile
Sp
ne
field?
la
a. Place the cap from the solution sterile side up on clean surface
sh
Sp
b. Open the outermost flap of the sterile kit toward the body→ flap
AWAY from the body's first
la
Sp
