ATI - Comprehensive C Exam

1. 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? - Document the client's condition every 15 minutes 2 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? - Administer analgesics on a scheduled basis for the first 24 hr 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 client who has a hip fracture and a new onset of tachypnea 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? - Wear gloves to apply the patch to the client's skin 5. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? - A client who was just given a glass of orange juice for a low blood glucose level 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 history of gastroesophageal reflux disease 7 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 8. 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? - Administer calcium gluconate IV 9. Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form ofcalcium 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 predictor of future violence? - Previous violent behavior 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). 10. 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 11. 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? - Eat a light snack before bedtime 12. 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? - Identify environmental hazards in the home 13. 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? - "What high school did you graduate from" 14. 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? - HbA1c level less than 7% 15. 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? - The client is showing evidence of phenytoin toxicity 16. 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) 17. 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? - Monitor the child's cardiac status 18. 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? - Use of tobacco decreases the level of athletic ability 19. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? - Serum potassium- diuretic that retains potassium= hyperkalemic risk 20. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? - "I will let the client know that I am available as the interpreter." 21. A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? - A two day old newborn who has a respiratory rate of 70 (30 - 60 is normal) 22. 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 client who has fractured left tibia and pallor in the affected extremity 23. 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? - Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported 24. 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? - 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 25. A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client? - Potato pancakes 26. 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? - Disorganized speech 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? - Apply an orthotic to the clients foot 28. 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? - Provide anticipatory guidance classes to parents through public schools 29. 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? - Below the knee amputation 30. 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? - Platelets 100,000/mm3 (150,000-300,00 risk for bleeding) 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? - Prealbumin 10 mcg/dl (normal: 16-40) 32. 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 client who is postoperative following a bowel resection with an NGT set to continuous suction 33. 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 deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ? - Continue the monitor the fetal heart rate (Not a problem- absent or late are a problem) 34. 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? - Compare the current infusion with the prescription in the client's medication record. 35. 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 ? - WBC count 2,900 /mm3 (Agrunlocytosis - 4,800-15,000 normal range) 36. 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? - You may breastfeed unless your nipples are cracked or bleeding. 37. 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? - Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ? 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? - Initiate seizure precautions 39. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include. - Document the client's conditions every 15 minutes 40. 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? - Iniang IV 1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing