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ATI CAPSTONE ADULT MEDICAL SURGICAL
ASSESSMENT
a nurse is assessing a pt who has a herniated lumbar disc, what finding would the nurse expect - ANSWER -the pt reports tingling and burning sensation in one foot a nurse is assessing a pt who has a history of migraine headaches with aura and reports feeling a "migraine coming on", the nurse should expect the pt to report what manifestation - ANSWER - visual disturbance a nurse is teaching a pt who has a new diagnosis of MS about visual changes she might experience as the disease progresses, what would she include? - ANSWER -double vision a nurse is teaching a pt who has asthma about using a peak flow meter, when a yellow zone meter reading appears, the nurse should instruct the pt to take which of the following actions - ANSWER -take prescribed relief meds a nurse is assessing a pt who has Addison's disease, what manifestation would indicate they are experiencing the crisis - ANSWER -hypotension (aldosterone deficit) a nurse is caring for pt who has acute gastritis and is NPO, the pt has a new prescription to resume oral intake, what item should the nurse offer the pt - ANSWER -gelatin
a nurse is providing education to a pt who is scheduled for a barium swallow, what statement indicates understanding of the teaching? - ANSWER -i will remove my metal jewelry before coming in a nurse is caring for pt who is undergoing a liver biopsy, what instruction should the nurse provide to the pt following the procedure - ANSWER -lie on your right side a nurse is teaching a pt who has a hiatal hernia about dietary selections to maintain lower esophageal sphincter (LES) pressure, what choice by the pt indicates understanding - ANSWER - cheddar cheese (avoid fried, fatty, peppermint, caffeine, tomatoes, citrus fruits, and alcohol) a nurse is reviewing the lab results of a pt who has unstable angina and has been receiving heparin via continuous IV infusion for the past 5 days, what lab values should the nurse identify as an indication that the pt has developed HIT - ANSWER -platelets 90, a nurse is teaching a pt who has a new diagnosis of polycystic kidney disease, what statement should the nurse include in the teaching - ANSWER -apply dry heat to your abdomen when needed
a nurse is caring for a pt who has renal caliculi, what prescription by the provider is the priority action for the nurse to take - ANSWER -strictly monitor intake and output a nurse is caring for a pt who is immediately postoperative following a pheochromocytoma removal, what action is priority - ANSWER -monitoring BP a nurse is assessing a female pt who reports severe joint pain, the nurse should identify which of the following factors places the pt at risk for gout - ANSWER -diuretic use a nurse is caring for a pt who has a cervical spinal cord injury, what interventions should the nurse include in the plan of care to prevent autonomic dysreflexia - ANSWER -monitor bowel movement regularity a nurse is caring for an adult client who asks about vaccinations against communicable diseases, the nurse should inform the client that which of the following vaccines are available - ANSWER -Hep A, Hep B, Pneumococcal a nurse is providing discharge instructions to a pt following a cataract surgery, the nurse should advise the pt that he can perform what activities - ANSWER -cooking light house work (avoid bending at the waist, or anything that can increase IOP)
a nurse is teaching a pt who has angina pectoris about nitroglycerin sublingual tablets, what statements should indicate to the nurse that the pt understands the teaching - ANSWER -i will keep the tablets in the original container a nurse is discussing risk factors for hep A with a newly licensed nurse, what client would the nurse identify as an increased risk for hep A - ANSWER -a client who has recently done missionary work in a developing country a nurse is providing discharge teaching to a pt who had a colposcopy with cervical biopsy, what instruction should the nurse provide - ANSWER -avoid the use of aspirin for cramping discomfort a nurse is caring for a pt who has a history of tonic clonic seizures, what precuation should the nurse take? - ANSWER -keep a suction apparatus at the bedside, keep the bed in the lowest position, keep oxygen equipment at the bedside a nurse is caring for a pt who is postop and reports frequent leakage of small amounts of urine, the nurse notes that the client's bladder is palpable upon examination, the nurse should identify these findings as what form of incontinence - ANSWER - overflow a nurse is assessing a pt who has a tension pneumothorax following blunt chest trauma, what should the nurse expect - ANSWER -tracheal deviation to the unaffected side
a nurse is reviewing lab reports for a pt who is taking NSAIs for RA, what results should the nurse recognize as a possible adverse effects of NSAID therapy - ANSWER -positive fecal occult blood test a nurse is teaching strategies to prevent carpal tunnel syndrome to a group of office workers, what instructions should the nurse include - ANSWER -use a wrist rest when working at a computer station stretch your fingers and wrists periodically while working take breaks from the repetitive activity a nurse is providing education regarding the prevention of UTIs to a client who has a history of cystitis, what statements by the client indicates that the teaching has been effective - ANSWER -i will empty my bladder every 2-3 hours throughout the day a nurse is providing discharge teaching to a pt who is postop following a total hip arthroplasty, what statement by the pt indicates an understanding of the teaching - ANSWER -i'll use my reaching device to help me pick up objects i drop on the floor a nurse is assessing a pt following a hypophysectomy, what finding indicates the client may be developing DI - ANSWER -low urine specific gravity a nurse is caring for a pt who has a history of peripheral vascular disease, what should alert the nurse to an increased risk of DVT? -
ANSWER -dehydration, combination oral contraceptives, immobility, hypercalcemia a nurse is caring for a pt who has a permanent pacemaker with a ventricular demand setting of 70, which of the following findings should alert the nurse to a pacemaker malfunction - ANSWER - apical pulse rate of 64/min a nurse is providing teaching to a pt who has a new onset of genital herpes, what statement should the nurse include in the teaching - ANSWER -stress can activate an outbreak a nurse is caring for pt who is postop following a total laryngectomy with radical neck dissection the nurse notes that the client is restless with a respiratory rate of 26/min and audible gurglin, what is a priority action by the nurse - ANSWER -suction the client's tracheostomy a nurse is assessing a pt who has right lower lobe pneumonia, what finding should the nurse expect? - ANSWER -dull percussion sounds a nurse is caring for a pt who is using a ventilator when the low- pressure ventilator alarm sounds, what actions should the nurse take? - ANSWER -check the ventilator tubing connectiosn a nurse is reviewing lab values for a client who has Cushing's disease, what values should the nurse expect - ANSWER -sodium 150
a nurse is caring for a pt who has mild dehydration, the pt has a peripheral IV and is prescribed 0.9% sodium chloride 1,000mL with 40 mEq potassium chloride to infuse in 1 hour, what action should the nurse take first - ANSWER -verify the prescription with the provider (risk for fluid overload and dysrhythmia from rapid potassium IV infusion) a nurse is teaching a group of APs about caring for clients with Alzheimer's disease, what info should the nurse include - ANSWER -provide supervision to prevent a pt from becoming injured or lost a nurse is providing teaching to a pt who has acute leukemia and received chemo 5 days ago, what instruction should the nurse include in the teaching - ANSWER -use an electric shaver avoid crowds monitor for bruising a nurse is caring for a pt who is at high risk for iron deficiency anemia, what foods should the nurse instruct the client to increase in her diet - ANSWER -raisins a nurse is planning care for a pt who has Meniere's disease and is experiencing episodes of vertigo, what intervention should the nurse include in the plan - ANSWER -provide a low-sodium diet (reduces fluid retention, reducing manifestations of the disease)
a nurse is providing discharge instructions to a pt who has a new AV fistula to the right forearm for hemodialysis, what statement should the nurse include - ANSWER -keep the right arm elevated above the level of your heart (prevents edema) a nurse is providing discharge teaching to a pt who has multiple sclerosis, what instruction should the nurse include in the teaching - ANSWER -it is important to develop a daily schedule that reduces fatigue and conserves energy a nurse is providing discharge teaching to a pt who has heart failure and a prescription for furosemide 20 mg PO two times a day, what instruction should the nurse include in the teaching - ANSWER -increase the intake of high potassium foods a nurse is providing discharge instructions to a pt who is to perform dressing changes to an incision at home, what statements by the pt indicates an understanding of the teaching - ANSWER -"I should wash my hands before both removing and applying the dressing" a home health nurse is caring for a pt who has COPD and is on home oxygen at 2L/min via nasal cannula, the pt tells the nurse that she is experiencing difficulty breathing, what action should the nurse take first - ANSWER -observe the pt's respiratory effort a nurse is caring for a pt who has right sided pneumothorax, following chest tube insertion what finding indicates that the
a nurse is providing dietary teaching to a pt who has chronic cholecystitis, what diet should the nurse recommend - ANSWER - low-fat diet a nurse is providing discharge teaching to a pt who is postop following a mitral valve replacement, what instruction should the nurse include in the teaching - ANSWER -obtain an antibiotic prescription before a dental procedure (r/f endocarditis) a nurse is providing teaching to a newly licensed nurse about caring for a pt who is receiving a sealed radioactive implant, what information should the nurse include in the teaching - ANSWER - wear a lead apron during care a nurse in a rural community center is providing education to clients about first aid interventions for snake bites, what should the nurse include - ANSWER -immobilize the affected extremity with a splint a nurse is providing teaching to a pt who is scheduled for exercise electrocardiography, what statements by the pt indicate understanding - ANSWER -i should avoid caffeinated beverages on the day of the test a nurse is caring for a pt who has a new diagnosis of TB, what precaution should the nurse initiate to prevent transmission of the disease - ANSWER -airborne precaution
a nurse is providing teaching to a pt who is scheduled for electromyography (EMG), the nurse should include what info in the teaching - ANSWER -you should expect insertion of small needle electrodes into the muscle a nurse is reviewing the med record of a pt who has unstable angina, what finding shoul dthe nurse report to the provider - ANSWER -breath sounds (crackles) a nurse is providing teaching to a pt who is newly diagnosed with nephrotic syndrome, what statement should indicate to the nurse that the pt understands the teaching - ANSWER -i can expect swelling in my hands and on my face (d/t loss of protein) a nurse is assessing a pt who has a heart rate of 40/min, the pt is diaphoretic and has chest pain, what medication should the nurse plan to administer - ANSWER -atropine a nurse is caringfor a pt who is scheduled to undergo bone marrow harvesting, the nurse should instruct the pt that the harvesting will occur in which of the following situations - ANSWER -in the OR under general anesthesia a nurse is caring for a pt who has a closed head injury, what following finding indicates the need for immediate intervention - ANSWER -respiratory rate 24/min with increased depth
a nurse is teaching a pt about using a CPAP, to treat obstructive sleep apnea, what should the nurse include in teaching - ANSWER -it delivers a preset amount of airway pressure throughout the breathing cycle a nurse is assessing a pt who has a sodium level of 122, what findings should the nurse expect - ANSWER -decreased deep- tendon reflexes a nurse is assessing a pt who has meningitis, the nurse should identify which of the following findings as a positive Kernig's sign - ANSWER -after hip flexion, the pt is unstable to extend his leg completely without pain a nurse in an emergency department is caring for a pt who has sustained multiple injuries, the nurse observes the pt's thorax moving inward during inspiration and outward during expiration, the nurse should suspect which of the following injuries - ANSWER -flail chest a nurse is teaching a pt who has osteoarthritis and is scheduled for a left hip arthroplasty, the nurse should explain that which of the following is the purpose of the procedure - ANSWER -improve joint range of motion a nurse is caring for apt who is postop following a bronchoscopy, what actions are the nurses priority - ANSWER -determine the pts gag reflex
a nurse is caring for a client who had an intravenous pyelogram (IVP) which of the following interventions should the nurse implement - ANSWER -encourage an increase in fluid intake a nurse is teaching a pt about fecal occult blood testing (FOBT) for the screening of colorectal cancer, what statement should the nurse include in the teaching - ANSWER -you should avoid eating red meat prior to testing a nurse is teaching a client who has hypertension about dietary modifications to help control BP, what food choices should the nurse recommend - ANSWER -3 oz of chicken breast a nurse is teaching a pt who has type 1 DM about hypoglycemia, what statement by the pt indicates an understanding of the teaching - ANSWER -i can drink 4 ounces of soda if my blood sugar is low a nurse is planning care for a client who has acute post- streptococcal glomerulonephritis, what interventions should the nurse include in the pt's plan of care - ANSWER -administer diuretics to the client (sodium and fluid restrictions help reduce edema that is characterized by glomerulonephritis)
