ATI - Comprehensive 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?
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?
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 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 take?
Wear gloves to apply the patch to the client's skin
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 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
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
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
Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an
injectable form of
calcium 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).
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
,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
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
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"
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%
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
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)
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
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
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
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."
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)
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
, 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
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
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
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
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
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
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
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)
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)
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 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
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
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
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
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 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
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
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
Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an
injectable form of
calcium 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).
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
,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
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
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"
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%
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
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)
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
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
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
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."
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)
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
, 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
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
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
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
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
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
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
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)
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)
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
