Riverside Community College (Riverside City Colleg
MAIN VE.RSION PRIO.RITY ONE
Exam (elaborations)
Exam (elaborations) MAIN VERSION PRIORITY ONE exit exam Solved
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MAIN VE.RSION PRIO.RITY ONE
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Riverside Community College (Riverside City Colleg
Exam (elaborations) MAIN VERSION PRIORITY ONE exit exam Solved
1. Missing
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 l...
Riverside Community College (Riverside City Colleg
MAIN VE.RSION PRIO.RITY ONE
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MAIN VERSION PRIORITY
ONE
1. Missing
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
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.
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 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
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)
Rationale https://medlineplus.gov/druginfo/meds/a601084.html : How to apply
patch Rationale ATI Skills Module Medication Administration: Topical
medications include lotions, creams, ointments, patches, and paste. Because topical
medications are absorbed by the skin, wear gloves when applying them to protect
yourself against accidental exposure
Shaving may cause skin irritation and change the absorption of the drug.
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 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.
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
,Questions and answers
c. Sitting in a high-Fowler’s position during the feeding
d. A residual of 65 mL 1hr postprandial
,Questions and answers
Rationale ATI MS p309: Complications: Aspiration of gastric secretion Causes: Reflux
of gastric fluids into the esophagus can be aspirated into the trachea.
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 INCREASED in which of the
following laboratory values?
a. Serum glucose level- increased
b. Serum calcium level-decreased
c. Lymphocyte count- decreased immune system.
d. Serum potassium level- decreased
Rationale ATI MS PDF p518: Cushing disease→ everything is UP except Potassium &
Calcium: DECREASED.
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? P .
235 pharm ch 30
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
Rationale ATI PHARM PDF p398: Calcium gluconate is given for magnesium sulfate
toxicity. Always have an injectable form of calcium gluconate available when
administering magnesium sulfate by 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
Rationale ATI MH p185: Risk factors also include: past history of aggression, poor
impulse control, and violence. Comorbidity that leads to acts of violence (psychotic
delusions, command hallucinations, violent angry reactions with cognitive disorders).
Rationale ATI COMMUNITY p50: Individual Assessment for Violence
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→ flap AWAY from
the body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field →
2.5 cm (1-inch) border around any sterile drape or wrap that is considered
contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist
level; should be ABOVE waist level
Rationale POTTER & PERRY SKILLS & TECH p187: Remove sterile seal and cap
from bottle in upward motion.
11. A nurse is providing teaching to an older adult client about methods to
promote nighttime sleep. Which of the following instructions should the nurse
include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime
12. A home health nurse is preparing for an initial visit with an older adult client who
lives alone. Which of the following actions should the nurse take first?
, Questions and answers
a. Educate the client about current medical diagnosis
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