ATI Comprehensive A

9. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? A. Rupture the amniotic sac B. Medicate the client for pain C. Prepare the client for a cesarean section D. Perform a vaginal exam - Answer- Prepare the client for a cesarean section 177. A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? A. Client fell out of bed because an assistive personnel left the rails of the bed down B. Client's roommate thinks the client is confused and fell when getting out of bed C. Client appears to have slipped in water but reports no injuries D. Client found lying on the floor near the bedside table - Answer- Client found lying on the floor near the bedside table 178. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treatments B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow D. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod - Answer- A 10-year-old client who has pneumonia and is receiving respiratory treatments 179. A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? A. Hepatotoxicity B. Ototoxicity C. Hypercalcemia D. Hypertension - Answer- Ototoxicity 180. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit - Answer- Thready pulse 1. A home h