ATI COMPREHENSIVE EXIT EXAM C 180 Q & A GRADED A

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? Request a renewal of the prescription every 8 hr. Check the client's peripheral pulse rate every 30 min Obtain a prescription for restraint within 4 hr. Document the client's condition every 15 minutes - 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? Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first) Give cromolyn nebulizer solution every 6 hr (for asthma) apply a warm compress to the operative site every 4 hr Administer analgesics on a scheduled basis for the first 24 hr - 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 sinus arrhythmia and is receiving cardiac monitoring A client who has diabetes mellitus and a hemoglobin A1C of 6.8% A client who has epidural analgesia and weakness in the lower extremities A client who has a hip fracture and a new onset of tachypnea - 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? 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 d. remove previous patch and place it in a tissue - b. 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 A client who is schedule for a procedure in 1 hr (can wait) A client who has 100 mL fluid remaining in his IV bag (can wait) A client who received a pain medication 30 min ago for postoperative pain - 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. A residual of 65mL 1 hr postprandial B. A History of gastroesophageal reflux disease C. Sitting in a high-Fowler's position during the feeding D. Receiving a high osmolarity formula - B. 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? a. Serum glucose level- increased b.Serum calcium level-decreased c. Lymphocyte count- decreased immune system. d. Serum potassium level- decreased - a. 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? Position the client supine Prepare an IV bolus of dextrose 5% in water Administer methylergonovine IM Administer calcium gluconate IV - Administer calcium gluconate IV 9. 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? a. Experiencing delusions b. Male gender c. Previous violent behavior d. A history of being in prison - c. Previous violent behavior 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? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field d. Set up the sterile field 5 cm (2 in) below waist level - a. 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? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day d. Perform exercises prior to bedtime - a. 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? a Educate the client about current medical diagnosis. b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments - c. 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? a. "Can you tell me who visited you today?" b. "What high school did you graduate from c. "Can you list your current medications?" d. "What did you have for breakfast yesterday?" - b. "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? a. HbA1c level greater than 8% b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfastd. HbA1c level less than 7% - d. 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? a. The client is experiencing an adverse reaction to rifampin b. The client's seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy - c. 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? a. Increase in frequency of swallowing b. Moderate sanguineous drainage on the drip pad c. Bruising to the face d. Absent gag reflex - a. Increase in frequency of swallowing 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? Give scheduled doses of acetaminophen every 6 hr Monitor the child's cardiac status Administer antibiotics via intermittent IV bolus for 24 hr Provide stimulation with children of the same age in the playroom - 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 might lead to alcohol and drug abuse Smoking in adolescence increases the risk of developing lung cancer later in life Use of tobacco decreases the level of athletic ability Smoking in adolescence increases the risk of lifelong addiction - 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? Total bilirubin Urine ketones Serum potassium Platelet count - Serum potassium 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." "I will receive a small fee for interpreting for this client." "I am glad I'm available today, but when I'm not, you can use a family member." "I will let the client know that an interpreter is unavailable during the night shift." - "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 A 16-hour old new newborn who has yet to pass meconium A 2-day old newborn who has a small amount of blood tinged vaginal discharge A 16 hr old newborn whose blood glucose is 45 mg/dL - A two day old newborn who has a respiratory rate of 70 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? A client who is 1 hr postoperative and has hypoactive bowel sounds A client who has fractured left tibia and pallor in the affected extremity A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses A client who has a elevated AST level following administration of azithromycin - 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? Weight gain Dry mouth Sedation Shuffling gait - Shuffling gait 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? Clean the base of the cord with hydrogen peroxide daily The cord stump will fall off in 5 days Contact the provider if the cord stump turns black Keep the cord stump dry until it falls off - Keep the cord stump dry until it falls off 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? White flour tortillas Potato pancakes Wheat crackers Canned barley soup - 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? All or nothing thinking Euphoric mood Disorganized speech Hypochondriasis - Disorganized speech 27. A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? Align a trochanter wedge between the clients legs Place a towel roll under the clients neck Apply an orthotic to the clients foot Position a pillow under the client's knees - 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? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution - a. 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 10cm (4 in) laceration Fractured tibia 95% full thickness body burn - 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? Hgb 12.8 g/dl Potassium 4.2 meq/l RBC 4.4 million/mm3 Platelets 100,000/mm3 - - Platelets 100,000/mm3 - 31. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? Iron 90 mcg/dl Prealbumin 10 mcg/dl Serum creatinine 0.8 mg/dl Calcium 9.5 mg/dl - Prealbumin 10 mcg/dl 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 A client who has fractured a femur yesterday and is expecting SOB A client who sustained a concussion and has unequal pupils A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs - 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 ? Stop the oxytocin infusion Perform a vaginal examination Initiate an amnioinfusion Continue to monitor the fetal heart rate - Continue to monitor the fetal heart rate 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? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescription in the client's medication record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident. - b. 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 FAsting blood glucose 100 mg/dl Hgb 14 g/Dl Heart rate 58/min - WBC count 2,900 /mm3 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. You must use a breast pump to provide breast milk. You must use nipple shield when breastfeeding. You may breastfeed after your baby develops his antibiotics. - 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? Exhibit. Level of consciousness Skin turgor Deep-tendon reflexes Bowel sounds - Level of consciousness 38. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ? Submerge the adolescent feet in ice water Cover the adolescent with a thermal blanket → if hypothermia. Administer oral acetaminophen Initiate seizure precautions - 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 Attach the restraints to the beds side rails Request a PRN restraints prescription for clients who are aggressive Remove the client restraints every 4 hours - 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? Providing pain management Offering emotional support Preventing infection Initiating IV fluid resuscitation - Initiating IV fluid resuscitation