ATI COMPREHENSIVE C
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 hr.
B.Check the client’s peripheral pulse rate every 30 min
C.Obtain a prescription for restraint within 4 hr.
D.Document the client’s condition every 15 minutes
2.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
3.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
4.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)
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