vATI vCOMPREHENSIVE vC
1. A vnurse vis vcaring vfor va vclient vwho vhas vbipolar vdisorder vand vis
vexperiencing vacute vmania. vThe vnurse vobtained va vverbal vprescription vfor
vrestraints. vWhich vof vthe vfollowing vshould vthe vactions vthe vnurse vtake?
A. Request va vrenewal vof vthe vprescription vevery v8 vhr.
B. Check vthe vclient’s vperipheral vpulse vrate vevery v30 vmin
C. Obtain va vprescription vfor vrestraint vwithin v4 vhr.
D. Document vthe vclient’s vcondition vevery v15 vminutes
2. A vnursing vplanning vcare vfor va vschool-age vchild vwho vis v4 vhr
vpostoperative vfollowing vperforated vappendicitis. vWhich vof vthe vfollowing
vactions vshould vthe vnurse vinclude vin vthe vplan vof vcare?
a. Offer vsmall vamounts vof vclear vliquids v6 vhr vfollowing vsurgery v(assess vfor
vgag vreflex vfirst)
b. Give vcromolyn vnebulizer vsolution vevery v6 vhr v(for vasthma)
c. Apply va vwarm vcompress vto vthe voperative vsite vevery v4 vhr
d. v v Administer vanalgesics von va vscheduled vbasis vfor vthe vfirst v24 vhr
3. A vnurse vis vreceiving vchange-of-shift vreport vfor va vgroup vof vclients.
vWhich vof vthe vfollowing vclients vshould vthe vnurse vplan vto vassess vfirst?
,a. A vclient vwho vhas vsinus varrhythmia vand vis vreceiving vcardiac vmonitoring
b. A vclient vwho vhas vdiabetes vmellitus vand va vhemoglobin vA1C vof v6.8%
c. A vclient vwho vhas vepidural vanalgesia vand vweakness vin vthe vlower
vextremities
d. v v A vclient vwho vhas va vhip vfracture vand va vnew vonset vof vtachypnea
4. A vnurse vis vpreparing vto vapply va vtransdermal vnicotine vpatch vfor va
vclient. vWhich vof vthe vfollowing vactions vshould vthe vnurse vtak ve?
a. v v Shave vhairy vareas vof vskin vprior vto vapplication v(apply vto vhairless,
vclean v& vdry vareas vto vpromote vabsorption; vavoid voily vor vbroken vskin)
b. v v Wear vgloves vto vapply vthe vpatch vto vthe vclient’s vskin
c. Apply vthe vpatch vwithin v1 vhr vof vremoving vit vfrom vthe vprotective vpouch
v(apply vimmediately)
d. Remove vthe vprevious vpatch vand vplace vit vin va vtissue v(fold vpatch vin
vhalf vwith vsticky vsides vpressed vtogether)
5. A vnurse vhas vjust vreceived vchange-of-shift vreport vfor vfour vclients.
vWhich vof vthe vfollowing vclients vshould vthe vnurse vassess vfirst?
a. v v v A vclient vwho vwas vjust vgiven va vglass vof vorange vjuice vfor va vlow
vblood vglucose vlevel
b. A vclient vwho vis vschedule vfor va vprocedure vin v1 vhr v(can vwait)
c. A vclient vwho vhas v100 vmL vfluid vremaining vin vhis vIV vbag v(can vwait)
d. A vclient vwho vreceived va vpain vmedication v30 vmin vago vfor vpostoperative
, vpain
6. A vnurse vis vcaring vfor va vclient vwho vis vreceiving vintermittent venteral
vtube vfeedings. vWhich vof vthe vfollowing vplaces vthe vclient vat vrisk vfor
vaspiration?
a. A vhistory vof vgastroesophageal vreflux vdisease
b. Receiving va vhigh vosmolarity vformula
c. Sitting vin va vhigh-Fowler’s vposition vduring vthe vfeeding
d. A vresidual vof v65 vmL v1hr vpostprandial
7. A vnurse vis vreviewing vthe vlaboratory vresults vfor va vclient vwho vhas
vCushing’s vdisease. vThe vnurse vshould vexpect vthe vclient vto vhave van vincrease
vin vwhich vof vthe vfollowing vlaboratory vvalues? va. v v v Serum vglucose
vlevel- vincreased v
, b. Serum vcalcium vlevel-decreased
c. Lymphocyte vcount- vdecreased vimmune vsystem.
d. Serum vpotassium vlevel- vdecreased
. v8. v A vnurse vis vcaring vfor va vclient vwho vhas vsevere vpreeclampsia vand
vis vreceiving vmagnesium vsulfate vintravenously. vThe vnurse vdiscontinues vthe
vmagnesium vsulfate vafter vthe vclient vdisplaces vtoxicity. vWhich vof vthe
vfollowing vactions vshould vthe vnurse vtake?
a. Position vthe vclient vsupine
b. Prepare van vIV vbolus vof vdextrose v5% vin vwater
c. Administer vmethylergonovine vIM
d. Administer vcalcium vgluconate vIV
Calcium vgluconate vis vgiven vfor vmagnesium vsulfate vtoxicity. vAlways vhave van
vinjectable vform vof vcalcium vgluconate vavailable vwhen vadministering vmagnesium
vsulfate vby vIV.
9. A vcharge vnurse vis vteaching vnew vstaff vmembers vabout vfactors vthat
vincrease va vclient’s vrisk vto vbecome vviolent. vWhich vof vthe vfollowing vrisk
vfactors vshould vthe vnurse vinclude vas vthe vbest vpredictor vof vfuture vviolence?
a. Experiencing vdelusions
b. Male vgender
1. A vnurse vis vcaring vfor va vclient vwho vhas vbipolar vdisorder vand vis
vexperiencing vacute vmania. vThe vnurse vobtained va vverbal vprescription vfor
vrestraints. vWhich vof vthe vfollowing vshould vthe vactions vthe vnurse vtake?
A. Request va vrenewal vof vthe vprescription vevery v8 vhr.
B. Check vthe vclient’s vperipheral vpulse vrate vevery v30 vmin
C. Obtain va vprescription vfor vrestraint vwithin v4 vhr.
D. Document vthe vclient’s vcondition vevery v15 vminutes
2. A vnursing vplanning vcare vfor va vschool-age vchild vwho vis v4 vhr
vpostoperative vfollowing vperforated vappendicitis. vWhich vof vthe vfollowing
vactions vshould vthe vnurse vinclude vin vthe vplan vof vcare?
a. Offer vsmall vamounts vof vclear vliquids v6 vhr vfollowing vsurgery v(assess vfor
vgag vreflex vfirst)
b. Give vcromolyn vnebulizer vsolution vevery v6 vhr v(for vasthma)
c. Apply va vwarm vcompress vto vthe voperative vsite vevery v4 vhr
d. v v Administer vanalgesics von va vscheduled vbasis vfor vthe vfirst v24 vhr
3. A vnurse vis vreceiving vchange-of-shift vreport vfor va vgroup vof vclients.
vWhich vof vthe vfollowing vclients vshould vthe vnurse vplan vto vassess vfirst?
,a. A vclient vwho vhas vsinus varrhythmia vand vis vreceiving vcardiac vmonitoring
b. A vclient vwho vhas vdiabetes vmellitus vand va vhemoglobin vA1C vof v6.8%
c. A vclient vwho vhas vepidural vanalgesia vand vweakness vin vthe vlower
vextremities
d. v v A vclient vwho vhas va vhip vfracture vand va vnew vonset vof vtachypnea
4. A vnurse vis vpreparing vto vapply va vtransdermal vnicotine vpatch vfor va
vclient. vWhich vof vthe vfollowing vactions vshould vthe vnurse vtak ve?
a. v v Shave vhairy vareas vof vskin vprior vto vapplication v(apply vto vhairless,
vclean v& vdry vareas vto vpromote vabsorption; vavoid voily vor vbroken vskin)
b. v v Wear vgloves vto vapply vthe vpatch vto vthe vclient’s vskin
c. Apply vthe vpatch vwithin v1 vhr vof vremoving vit vfrom vthe vprotective vpouch
v(apply vimmediately)
d. Remove vthe vprevious vpatch vand vplace vit vin va vtissue v(fold vpatch vin
vhalf vwith vsticky vsides vpressed vtogether)
5. A vnurse vhas vjust vreceived vchange-of-shift vreport vfor vfour vclients.
vWhich vof vthe vfollowing vclients vshould vthe vnurse vassess vfirst?
a. v v v A vclient vwho vwas vjust vgiven va vglass vof vorange vjuice vfor va vlow
vblood vglucose vlevel
b. A vclient vwho vis vschedule vfor va vprocedure vin v1 vhr v(can vwait)
c. A vclient vwho vhas v100 vmL vfluid vremaining vin vhis vIV vbag v(can vwait)
d. A vclient vwho vreceived va vpain vmedication v30 vmin vago vfor vpostoperative
, vpain
6. A vnurse vis vcaring vfor va vclient vwho vis vreceiving vintermittent venteral
vtube vfeedings. vWhich vof vthe vfollowing vplaces vthe vclient vat vrisk vfor
vaspiration?
a. A vhistory vof vgastroesophageal vreflux vdisease
b. Receiving va vhigh vosmolarity vformula
c. Sitting vin va vhigh-Fowler’s vposition vduring vthe vfeeding
d. A vresidual vof v65 vmL v1hr vpostprandial
7. A vnurse vis vreviewing vthe vlaboratory vresults vfor va vclient vwho vhas
vCushing’s vdisease. vThe vnurse vshould vexpect vthe vclient vto vhave van vincrease
vin vwhich vof vthe vfollowing vlaboratory vvalues? va. v v v Serum vglucose
vlevel- vincreased v
, b. Serum vcalcium vlevel-decreased
c. Lymphocyte vcount- vdecreased vimmune vsystem.
d. Serum vpotassium vlevel- vdecreased
. v8. v A vnurse vis vcaring vfor va vclient vwho vhas vsevere vpreeclampsia vand
vis vreceiving vmagnesium vsulfate vintravenously. vThe vnurse vdiscontinues vthe
vmagnesium vsulfate vafter vthe vclient vdisplaces vtoxicity. vWhich vof vthe
vfollowing vactions vshould vthe vnurse vtake?
a. Position vthe vclient vsupine
b. Prepare van vIV vbolus vof vdextrose v5% vin vwater
c. Administer vmethylergonovine vIM
d. Administer vcalcium vgluconate vIV
Calcium vgluconate vis vgiven vfor vmagnesium vsulfate vtoxicity. vAlways vhave van
vinjectable vform vof vcalcium vgluconate vavailable vwhen vadministering vmagnesium
vsulfate vby vIV.
9. A vcharge vnurse vis vteaching vnew vstaff vmembers vabout vfactors vthat
vincrease va vclient’s vrisk vto vbecome vviolent. vWhich vof vthe vfollowing vrisk
vfactors vshould vthe vnurse vinclude vas vthe vbest vpredictor vof vfuture vviolence?
a. Experiencing vdelusions
b. Male vgender
