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
...
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)
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
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
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- increased
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