CC PROCTOR 1

1. 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. Request a renewal of the prescription every 8 hour. B. Check the client's peripheral pulse rate every 30 minutes. C. Obtain a prescription for restraint within 4 hr. D. Document the client's condition every 15 minutes. - C. Obtain a prescription for restraint within 4 hr. 2. A nurse is 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. B. Give Cromolyn nebulizer solution every 6 hr C. Apply a warm compress to the operative site every 4 hr. D. Administer analgesics on a scheduled basis for the first 24 hr. - D. Administer analgesics on a scheduled basis for the first 24 hr. 3. A nurse is receiving change-of-shift report for a group of clients. Which of the following should the nurse 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. - D. A client who has a hip fracture and a new onset of tachypnea. 4. A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? 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. D. Remove the previous patch and place it in a tissue. - B. Wear gloves to apply the patch to the client's skin. 5. 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 OJ for low blood glucose level. B. A client who is scheduled for a procedure in 1 hr C. A client who has 200mL fluid remaining in his IV bag D. A client who received a pain medication 30 minutes ago for postoperative pain. - A. A client who was just given a glass of OJ for low blood glucose level. 6. 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. A history of gastroesophageal reflux disease 7. 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 B. Serum calcium level C. Lymphocyte count D. Serum potassium - A. Serum glucose level 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 - D. Administer calcium gluconate 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 - C. Previous violent behavior 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. C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. D. Set up the sterile field 5 cm (2 in) below waist level - A. Place the cap from the solution sterile side up on clean surface