ATI Capstone Adult Medical Surgical Assessment 2.pdf | Exams Nursing

ATI Capstone Adult Medical Surgical Assessment 2

*Inject air into NPH insulin vial

*Withdraw short-acting insulin into syrgine

*Roll NPH vial between palms of hands

*Inspect vials for contaminants

*Inject air into regular insulin vial

*Add intermediate insulin to syringe - ans*Inspect vials for contaminants

*Roll NPH vial between palms of hands

*Inject air into NPH insulin vial

*Inject air into regular insulin vial

*Withdraw short-acting insulin into syringe

*Add intermediate insulin to syringe

A nurse is preparing to administer a measles, mumps, and rubella vaccine (MMR) to an adult client. Which of the following is a

contraindication to this vaccine?

1) The possibility of pregnancy within 4 weeks

2) Client allergy to strawberries

3) Client history of genital herpes

4) The possibility of overseas travel in the next month - ans1) The possibility of pregnancy within 4 weeks

Pregnancy or the possibility of pregnancy with 4 weeks is a contraindication to the MMR vaccine

A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the

medication using the ventrogluteal site?

1) a 45 degree angle

2) a 60 degree angle

3) a 75 degree angle

4) a 90 degree angle - ans4) a 90 degree angle

IM injections should be administered at a 90 degree angle

A nurse is preparing to administer bisacodyl suppository to a client. Which of the following actions should the nurse take? Select all

that apply

*Don sterile gloves

*Lubricate index finger

*Use a rectal applicator for insertion

*Position client supine with knees bent

*Insert suppository just beyond internal sphincter - ans*Lubricate index finger

*Insert suppository just beyond internal sphincter

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should

the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) -

ans0.2 mL

A nurse is providing care to a client with staphylococcus epidermidis, who is prescribed vancomycin. Identify the adverse effect

associate with the antibiotic therapy?

1) Hepatotoxicity

2) Constipation

3) Infusion reaction

4) Immunosuppression - ans3) Infusion reaction

Red Man Syndrome or an infusion reaction that results in rashes, flushing, tachycardia and hypotension can occur as an adverse

reaction. For this reason, vancomycin should be administered over a 60 minute period

A nurse is reviewing the medication class benzodiazepines. The nurse would use cautions when administering benzodiazepines to

which of the below clients?

1) A client with glaucoma

2) A client with renal failure

3) A client with hypertension

4) A client with insomnia - ans1) A client with glaucoma

Benzodiazepines can increase intraocular pressure due to the pupil-dilating effects of the medication

Before administering blood products, which action should be taken?

1) Assess the client's temperature

2) Document client response

3) Prime IV tubing with 0.45% sodium chloride

4) Administer epinephrine - ans1) Assess the client's temperature

Partial preview of the text

Download ATI Capstone Adult Medical Surgical Assessment 2.pdf and more Exams Nursing in PDF only on Docsity!

*Inject air into NPH insulin vial *Withdraw short-acting insulin into syrgine *Roll NPH vial between palms of hands *Inspect vials for contaminants *Inject air into regular insulin vial Add intermediate insulin to syringe - ansInspect vials for contaminants *Roll NPH vial between palms of hands *Inject air into NPH insulin vial *Inject air into regular insulin vial *Withdraw short-acting insulin into syringe *Add intermediate insulin to syringe A nurse is preparing to administer a measles, mumps, and rubella vaccine (MMR) to an adult client. Which of the following is a contraindication to this vaccine?

The possibility of pregnancy within 4 weeks
Client allergy to strawberries
Client history of genital herpes
The possibility of overseas travel in the next month - ans1) The possibility of pregnancy within 4 weeks Pregnancy or the possibility of pregnancy with 4 weeks is a contraindication to the MMR vaccine A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
a 45 degree angle
a 60 degree angle
a 75 degree angle
a 90 degree angle - ans4) a 90 degree angle IM injections should be administered at a 90 degree angle A nurse is preparing to administer bisacodyl suppository to a client. Which of the following actions should the nurse take? Select all that apply *Don sterile gloves *Lubricate index finger *Use a rectal applicator for insertion *Position client supine with knees bent Insert suppository just beyond internal sphincter - ansLubricate index finger *Insert suppository just beyond internal sphincter A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - ans0.2 mL A nurse is providing care to a client with staphylococcus epidermidis, who is prescribed vancomycin. Identify the adverse effect associate with the antibiotic therapy?
Hepatotoxicity
Constipation
Infusion reaction
Immunosuppression - ans3) Infusion reaction Red Man Syndrome or an infusion reaction that results in rashes, flushing, tachycardia and hypotension can occur as an adverse reaction. For this reason, vancomycin should be administered over a 60 minute period A nurse is reviewing the medication class benzodiazepines. The nurse would use cautions when administering benzodiazepines to which of the below clients?
A client with glaucoma
A client with renal failure
A client with hypertension
A client with insomnia - ans1) A client with glaucoma Benzodiazepines can increase intraocular pressure due to the pupil-dilating effects of the medication Before administering blood products, which action should be taken?
Assess the client's temperature
Document client response
Prime IV tubing with 0.45% sodium chloride
Administer epinephrine - ans1) Assess the client's temperature

Assess the client's vital signs, obtain consent for the procedure and ensure compatibility. Prime the IV tubing with 0.9% sodium chloride. The nurse would not document client response or administer epinephrine prior to starting the transfusion Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?

Hepatoxicity
Wernicke's aphasia
Suicidal ideations
Diarrhea - ans1) Hepatoxicity Hepatoxicity is an adverse effect of disulfiram Which of the following are contraindications to salicylate acid therapy? Select all that apply *Third trimester pregnancy *Thrombocytopenia *Coronary artery disease *Adolescents with chickenpox Deep vein thrombosis - ansThird trimester pregnancy *Throbocytopenia *Adolescents with chickenpox Salicylate Acid Therapy Contraindications: Salicylate acid is a category D agent and should not be administered to pregnant clients. Salicylate acid is contraindicated in clients with bleeding disorders and thrombocytopenia. Salicylate acid should not be given to children or adolescents with fever or recent chickenpox due to the risk of Reye's syndrome. The therapy is used for the following types of clients: Salicylate acid inhibits platelet aggregation and is often used in the treatment and prevention of thrombosis. Salicylate acid is commonly prescribed to clients with coronary artery disease to prevent thrombus formation A nurse enters a client's room and finds the client on the floor experiencing a seizure. Which of the following actions should the nurse take? - ANSPosition the client on their side. The nurse should position the client on their side. This assists the client's airway to remain open and can prevent aspiration if the client has emesis or secretions in their mouth. A nurse is assessing a client who has enlarged lymph nodes. In which of the following locations should the nurse palpate to locate the postauricular nodes? - ANSOver the mastoid The nurse should palpate over the mastoid or behind the ear to assess the postauricular nodes. The detection of an enlarged or tender lymph node can indicate the presence of an infection or a malignancy and should be reported to the provider. A nurse is assessing a client who has multiple sclerosis. Which of the following assessments is the nurse's priority? - ANSAbility to swallow The greatest risk to the client is aspiration due to dysphagia. Therefore, the nurse's priority assessment is the client's ability to swallow. A nurse is assisting a client to ambulate to the bathroom when the client begins to fall. Which of the following actions should the nurse take? - ANSPlace one foot in front of the other while spreading the feet apart. The nurse should place one foot in front of the other while spreading the feet farther apart to widen their own base of support. Then the nurse should lower the client to the floor as smoothly as possible. This will assist with supporting the client's weight and help to prevent injury to the nurse. A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment is present in the client's room? - ANSAn obturator The nurse should ensure that a client who has a tracheostomy has an obturator at their bedside. If the tracheostomy is dislodged, an obturator is used to reinsert the outer cannula of the tracheostomy. The nurse should also ensure that a spare tracheostomy of the client's size, as well as a tracheostomy of one size smaller, supplemental humidified air or oxygen, and suction equipment are at the client's bedside to ensure safe client care. A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates that the nurse should modify the client's plan of care? - ANSReports pain as a 5 on a scale of 0 to 10

Orthostatic hypotension
Headache
Productive cough - ans4) Productive cough Nitroglycerin therapy does not directly have an effect lung function. Physiologically, vasodilation should effect capillary perfusion and decrease lung secretions A 55-year-old client has levothyroxine ordered. Which of the below past medical history concerns may contraindicate with her medication management of hypothyroidism?
Scleroderma
Osteoporosis
Asthma
Peripheral Vascular Disease - ans2) Osteoprosis There is an increased risk for fracture, especially in older adults A client has been prescribed isosorbide monoitrate. Which of the following should the nurse include in this client's education related to this medication?
This medication is prescribed for long-term therapy prophylaxis against anginal attacks
You can crush this medication if needed
Take the medication in the evening after dinner
Take an additional tablet if you experience chest pain - ans1) This medication is prescribed for long-term prophylaxis against anginal attacks Isosorbide mononitrate is used for long-term prophylaxis against anginal attacks A client has been prescribed lisinopril. Which of the following medication interactions should the nurse instruct this client about?
Potassium supplements
Ciprofloxacin
Escitalopram
Magnesium supplements - ans1) Potassium supplements Potassium supplements and potassium-sparing diuretics increase the risk of hyperkalemia in clients taking ACE inhibitors such as lisinopril. Clients should only take potassium supplements if prescribed by the provider. Clients should also avoid salt substitutes that contain potassium A client has been prescribed metoclopramide. Which of the following should the nurse include in client education regarding this medication?
Notify your provider if you experience restlessness or spasms of the face or neck
This medication can cause insomnia
Decrease your fluid intake while taking this medication
This medication can cause urinary frequency - ans1) Notify your provider if your experience restlessness or spams of the face or neck An adverse effect of metoclopramide is extrapyramidal symptoms. The client should stop the medication and notify the provider if these occur A client has been prescribed vasopressin for the treatment of diabetes insipidus. What is the expected pharmacologic actions of this medication?
To stimulate the pancreas to secrete insulin
To slow the absorption of glucose in the intestine
To increase reabsorption of water in the renal tubules
To increase blood pressure - ans3) To increase reabsorption of water in the renal tubules The expected pharmacologic action is to promote reabsorption of water within the kidney A client is prescribed propanolol. Which of the following client history findings would require the nurse to clarify this medication prescription?
Asthma
Hypertension
Tachydysrhythmias
Urolithiasis - ans1) Asthma Clients with asthma should avoid Beta2 Blockade agents such as propanolol. Brochoconstriction can occur. Clients with asthma should be administered a beta1 selective agent A nurse has just administered a wrong medication to a client. Which of the following actions should the nurse take next?

No action is needed
Report error to the provider
Complete an institutional incident report
Inform the client that the wrong medication was given - ans2) Report the error to the provider The nurse should acknowledge the error and report it to the provider for further orders. The nurse should also monitor the client for adverse effects. The nurse should also complete an incident report per institutional policy after notifying the health care provider A nurse have provided education to a client regarding prescribed levothyroxene sodium. What of the following client statements demonstrates understanding of medication administration?
"I should take my medication as needed to alleviate symptoms"
"I should take the medication in divided doses to ensure therapeutic drug levels"
"I should take the medication in the morning to prevent insomnia"
"I should take the medication on a full stomach" - ans3) "I should take the medication in the morning to prevent insomnia" Levothyroxene sodium should be taken once in the morning to prevent insomnia A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?
Change positions slowly and lie down if dizziness occurs
There is no need to avoid normal activities
Avoid dairy products while taking this medication
Do not eat green leafy vegetables - ans1) Change positions slowly and lie down if dizziness occurs First-dose orthostatic hypotension can occur with doxazosin. The nurse should instruct clients to change position slowly and to lie down if feeling dizzy, lightheaded or faint A nurse is caring for a client prescribed digoxin. Which of the following should alert the nurse to possible digitalis toxicity?
anorexia and weakness
hyperactivity and hunger
tachycardia and increased urination
polyphagia and polydipsia - ans1) anorexia and weakness Anorexia, fatigue and weakness are signs of potential digitalis toxicity. GI effects of digitalis toxicity include anorexia, nausea, vomiting, and abdominal pain. CNS effects include fatigue, weakness, vision changes (diplopia, blurred vision, yellow-green or white halos around objects). Bradycardia is also commonly noted in digitalis toxicity A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?
Take the medication on an empty stomach to maximize absorption
Notify your provider if your stool becomes dark green
Decrease dietary fiber intake while taking this medication
Take prescribed antacids at the same time as this medication - ans1) Take this medication on an empty stomach to maximize absorption The nurse should instruct the clients to take iron on an empty stomach, such as 1 hr before meals to maximize absorption. Stomach acid increases absorption. If GI adverse effects occur, the client can take with food to increase adherence to therapy even though absorption is also decreased A nurse is caring for a client prescribed HMG CoA reductase inhibitor, atorvastatin. Which of the following should be monitored while this medication is prescribed?
Liver function tests
Renal function tests
Visual acuity screening
Hearing screenings - ans1) Liver function tests Statins (HMG CoA reductase inhibitors) like atorvastatin can cause hepatotoxicity. Prior to initiating therapy the client's baseline liver function should be determined then liver function tests should be checked after 12 weeks of therapy and then every 6 months. The nurse should advise the client to observe for symptoms of liver dysfunction (anorexia, vomiting, nausea, jaundice) and to notify the provider if these occur A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medication should the nurse prepare to administer?
Flumazenil
Naloxone
Activated charcoal
Aluminum hydroxide - ans2) Naloxone

ATI Capstone Adult Medical Surgical Assessment 2.pdf, Exams of Nursing

Related documents

Partial preview of the text

Download ATI Capstone Adult Medical Surgical Assessment 2.pdf and more Exams Nursing in PDF only on Docsity!