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)

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