MAIN VERSION PRIORITY ONE.docx Exit Exam.
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)
R
a
t
i
on
a
l
e
h
tt
ps
:
/
/
m
e
dl
i
n
e
pl
u
s
.
g
o
v
/
d
r
u
gi
n
f
o
/
m
e
ds
/
a
6
0
1
0
8
4
.
h
t
m
l
:
H
o
w
t
o
a
pply
pa
tch
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
