MAIN VERSION PRIORITY ONE Exit Exam. 180 Questions and Answers. Top Grade

MAIN VERSION PRIORITY ONE EXIT EXAM 1. 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 Rationale Fundamentals ATI PDF p229: Managing acute severe pain with short-term (24 to 48 hr) around-the-clock administration of opioids is preferable to following a PRN schedule. ATI PEDS 144 Maintain NPO. Administer IV fluids and antibiotics as prescribed. NO cromolyn nebulizer stated on ATI. 2. 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 Rationale Med Surg ATI PDF p457: s/s of fat embolism (dyspnea, increased RR, decreased O2, headache, decreased LOC r/t low O2 levels, respiratory distress, tachycardia, confusion, chest pain), Hip and pelvis fractures are common causes, can occur after injury usually within 12-48 hrs 3. 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) Rationale Shaving may cause skin irritation and change the absorption of the drug. 4. 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 Rationale Med Surg ATI PDF p529: assess for improvement or worsening of hypoglycemia. Repeat the administration of carbohydrates if not within normal limits, and recheck blood glucose in 15 min. Risk for seizure & coma if condition worsens. 5. 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