1 patient refused a newly open fentanyl patch which of the following actions should the nurse take as
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Rasmussen College
CAPSTONE NUR2944
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RN Comprehensive Online Practice B/ Comprehensive
ATI Practice B (version 1)
1. Patient refused a newly open fentanyl patch. Which of the following actions should the
nurse take?
Ask another nurse to witness the disposal of the new patch.
2. Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values
are aPTT 98 seconds and INR 1.8
Withhold the heparin infusion
3. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one
eye . Which indicates the client has a detached retina
Floating dark spots
4. infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement
. finding to report to provider
Irritability when being held. signifies increased ICP
5. Assessing a newborn heart rate follow actions the nurse should take
Auscultate the apical pulse and count beats for at least 1 min.
6. Caring for a client who has a fecal impaction actions to be taken when digitally
evacuating the stool
Insert a lubricated gloved finger and advance along the rectal wall.
7. Dietary teaching for a new prescription of phenelzine
Broccoli, Yogurt, Cream Cheese
8. Nurse administers incorrect dose of medication. Which facts related to incident report
, should the nurse document in the client's medical record?
Time the medication was given
9. Nurse on pediatric unit received shift report on 4 children. Which should the nurse
assess first?
A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden
relief of pain. Can indicate peritonitis from a ruptured appendix.
10.Community health nurse providing teaching on home safety for older adults
Have grab bars installed around your bathtub and toilet.
11.School age child with scald burns on both hands and wrists suspected abuse
Contact child protective services.
12.Client who has acute blood loss following trauma refuses potentially life saving blood
transfusion
Explore the client's reasons fro refusing the treatment
13.Discussing common prenatal discomfort 20 weeks gestational
I will wear a supportive bra overnight
14.Discharge instructions to client to received home oxygen therapy
Wear clothing made with cotton fabrics while oxygen is in use.
15.Preparing an educational session about advocacy to a group of nurses
Advocacy is a leadership role that helps others to self actualize
16.Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and
decreased urinary output
Irrigate the catheter with 0.9% sodium chloride irrigation
, 17.Child with sickle cell anemia and is having a vaso-occlusive crisis
Infuse IV fluids
18.Client teaching about the basal body temp method for birth control
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