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 whohas 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)