ATI RN Comprehensive Exam C

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take? 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 of care? 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 nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? 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 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 nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following Document the client's condition every 15 minutes Administer analgesics on a scheduled basis for the first 24 hr A client who has a hip fracture and a new onset of tachypnea Wear gloves to apply the patch to the client's skin A client who was just given a glass of orange juice for a low blood glucose level A history of gastroesophageal reflux disease Serum glucose level- increased Administer calcium gluconate IV Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV. Previous violent behavior Risk factors also include: past history of aggression, poor impulse risk factors should the nurse include as the best predictor of future control, and violence. Comorbidity that leads to acts of violence 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? A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take 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? A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? 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 should the nurse conclude if the client develops ataxia and incoordination? 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? (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders). Place the cap from the solution sterile side up on clean surface Eat a light snack before bedtime Identify environmental hazards in the home "What high school did you graduate from" HbA1c level less than 7% The client is showing evidence of phenytoin toxicity Increase in frequency of swallowing (may indicate bleeding) 2 / 11 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 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? A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? A nurse has agreed to serve as an interpreter for an older adult Monitor the child's cardiac status Use of tobacco decreases the level of athletic ability Serum potassium- diuretic that retains potassium= hyperkalemic client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? 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 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 to the provider? A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching? 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 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? A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? 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? 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? A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? 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 nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early "I will let the client know that I am available as the interpreter." A two day old newborn who has a respiratory rate of 70 (30 - 60 is normal) A client who has fractured left tibia and pallor in the affected extremity Shuffling gait ’A/E EPS: is an indication of parkinsonism and should be reported 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 Potato pancakes Disorganized speech Apply an orthotic to the clients foot Provide anticipatory guidance classes to parents through public schools Below the knee amputation Platelets 100,000/mm3 (150,000-300,00 risk for bleeding) Prealbumin 10 mcg/dl (normal: 16-40) A client who is postoperative following a bowel resection with an NGT set to continuous suction Continue the monitor the fetal heart rate risk ATI - Comprehensive C Study online at 3 / 11 deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ? A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 90.7 (200 lb). The nurse should identify the weight of the following total percentage? A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanch- (Not a problem- absent or late are a problem) Compare the current infusion with the prescription in the client's medication record. WBC count 2,900 /mm3 (Agrunlocytosis - 4,800-15,000 normal range) You may breastfeed unless your nipples are cracked or bleeding. Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? Initiate seizure precautions Document the client's conditions every 15 minutes Iniang IV 1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing - Let's talk about your mom's cancer and how things will progress from here. - Tell me how you are feeling about your mom dying. - You sound like you have questions about your mom dying. Let's talk about it. A client who received a Mantoux test 48 hours ago and has induration Clarify the source of the referral You have the right to decide who receives information 7.5% Pour water from a squeeze bottle over the client's perineal area. Avoid hot tub while wearing the patch Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic)