RN ATI CAPSTONE COMPREHENSIVE C.pdf
● A nurse is caring for a client who has bipolar disorder and is
experiencing acute mania. The nurse obtained a verbal prescription
for restraints. Whichof the following should the actions the nurse
take?
A. Request a renewal of the prescription every 8 hr...
● A nurse is caring for a client who has bipolar disorder and is
experiencing acute mania. The nurse obtained a verbal prescription
for restraints. Whichof the following should the actions the nurse
take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client’s peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client’s condition every 15 minutes
● 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. Offer small amounts of clear liquids 6 hr following surgery (assess for
gag reflex first)
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
c. Apply a warm compress to the operative site every 4 hr
d. Administer analgesics on a scheduled basis for the first 24 hr
● 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. A client who has sinus arrhythmia and is receiving cardiac monitoring
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
c. A client who has epidural analgesia and weakness in the lower
extremities
d. A client who has a hip fracture and a new onset of tachypnea
● A nurse is preparing to apply a transdermal nicotine patch for a
client. Which of the following actions should the nurse tak e?
,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
(apply immediately)
d. Remove the previous patch and place it in a tissue (fold patch in
half with sticky sides pressed together)
● A nurse has just received change-of-shift report for four clients.
Which of the following clients should the nurse assess first?
a. A client who was just given a glass of orange juice for a low blood
glucose level
b. A client who is schedule for a procedure in 1 hr (can wait)
c. A client who has 100 mL fluid remaining in his IV bag (can wait)
d. A client who received a pain medication 30 min ago for postoperative
pain
● 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 history of gastroesophageal reflux disease
b. Receiving a high osmolarity formula
c. Sitting in a high-Fowler’s position during the feeding
d. A residual of 65 mL 1hr postprandial
● 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
. 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?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
Calcium gluconate is given for magnesium sulfate toxicity. Always have an
injectable form of calcium gluconate available when administering
magnesium sulfate by 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
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).
Individual Assessment for Violence
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→ flap
AWAY from the body's first
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