ATI - Comprehensive C, CP retake
take 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
Lab Values
Hgb 14-24
Hct 44-64
RBC 4.8-7.1
WBC 9-30
PLT 150-300
Glucose 40-60
Acid Base
pH 7.35- 7.45
PCO2 35-45
HCO3 22-26
respiratory acidosis low pH, high CO2
respiratory alkalosis high pH, low CO2
met alkalosis high pH, high HCO3
met acidosis low pH, low HCO3
care 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
first 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
take 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
first 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
aspiration 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
values 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
take 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
,violence 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
field 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
client 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"
teaching 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%
incoordination 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
nurse 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)
care 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
tobacco 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
client 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
role 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."
provider 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)
paresthesia 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
,provider 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
teaching 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
client 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
contracture 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
take 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
priority 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
report 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)
finding 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)
LPN 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
take 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
Continue the monitor the fetal heart rate
(Not a problem- absent or late are a
problem)
, take 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
Compare the current infusion with the prescription in the client's medication record.
clozapine 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
appropriate 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.
information 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
Level of consciousness.
take A nurse is caring for a client who has hyperthermia .Which of the following
actions for the nurse to take
Initiate seizure precautions
include 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
intervention 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
Iniang IV 1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing
appropriate A nurse is caring for a client who has cancer and is being transferred
to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to
my mom if she asks me about dying." which of the following responses by the
nurse is appropriate
- Let's talk about your mom's cancer and how things will progress from here.
- Tell me how you are feeling about your mom dying.
- You sound like you have questions about your mom dying. Let's talk about it.
care A nurse is reviewing the medical records of four clients. The nurse should
identify that which of the following client findings follow up care
A client who received a Mantoux test 48 hours ago and has induration
first A community health nurse receives a referral for a family home visit. Which
of the following tasks should the nurse perform first
Clarify the source of the referral
make A nurse is caring for a client who will undergo a procedure. The client
states he does not want the provider to discuss the results with his partner.
Which of the following is an appropriate response for the nurse to make
You have the right to decide who receives information
take 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
Lab Values
Hgb 14-24
Hct 44-64
RBC 4.8-7.1
WBC 9-30
PLT 150-300
Glucose 40-60
Acid Base
pH 7.35- 7.45
PCO2 35-45
HCO3 22-26
respiratory acidosis low pH, high CO2
respiratory alkalosis high pH, low CO2
met alkalosis high pH, high HCO3
met acidosis low pH, low HCO3
care 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
first 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
take 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
first 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
aspiration 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
values 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
take 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
,violence 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
field 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
client 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"
teaching 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%
incoordination 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
nurse 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)
care 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
tobacco 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
client 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
role 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."
provider 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)
paresthesia 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
,provider 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
teaching 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
client 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
contracture 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
take 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
priority 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
report 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)
finding 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)
LPN 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
take 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
Continue the monitor the fetal heart rate
(Not a problem- absent or late are a
problem)
, take 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
Compare the current infusion with the prescription in the client's medication record.
clozapine 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
appropriate 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.
information 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
Level of consciousness.
take A nurse is caring for a client who has hyperthermia .Which of the following
actions for the nurse to take
Initiate seizure precautions
include 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
intervention 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
Iniang IV 1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing
appropriate A nurse is caring for a client who has cancer and is being transferred
to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to
my mom if she asks me about dying." which of the following responses by the
nurse is appropriate
- Let's talk about your mom's cancer and how things will progress from here.
- Tell me how you are feeling about your mom dying.
- You sound like you have questions about your mom dying. Let's talk about it.
care A nurse is reviewing the medical records of four clients. The nurse should
identify that which of the following client findings follow up care
A client who received a Mantoux test 48 hours ago and has induration
first A community health nurse receives a referral for a family home visit. Which
of the following tasks should the nurse perform first
Clarify the source of the referral
make A nurse is caring for a client who will undergo a procedure. The client
states he does not want the provider to discuss the results with his partner.
Which of the following is an appropriate response for the nurse to make
You have the right to decide who receives information
