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)