Capstone ATI NCLEX Medical Surgical Assessment 1 2024-2025. Questions & Correct. Grade A+, Exams of Nursing

Download Capstone ATI NCLEX Medical Surgical Assessment 1 2024-2025. Questions & Correct. Grade A+ and more Exams Nursing in PDF only on Docsity! Capstone ATI NCLEX Medical Surgical Assessment 1 2024-2025. Questions and Correct, verified Answers. Graded A+ A nurse in a postanesthesia care unit is performing a postoperative assessment on a client who is recovering from a lumbar laminectomy and has a surgical drain. Which of the following findings should the nurse identify as a complication of the procedure A. Clear drainage on the surgical dressing B. Pain level of 5 on a scale from 0 to 10 C. Reports discomfort when log rolling D. Drainage output 30m: during the first hour - ANSA. Clear drainage on the surgical dressing Clear fluid on or around the surgical dressing following a laminectomy is an indication of CSF leak. Place the client flat to prevent a spinal headache and notify provider immediately A nurse in an emergency department is monitoring a client who reports angina. Which of the following findings should indicate to the nurse that the client might have experienced a myocardial infarction (MI) A. Increased troponin B. Decreased creatinine kinase MB C. Cholesterol 300 mg/dL D. C- reactive protein 1.2 mg/dL - ANSA ) Increased troponin Troponin is a myocardial muscle protein released into the blood stream as a result of injury to the heart muscle. Troponin levels increase within 2-3 hr following an MI A nurse in an endoscopy clinic is providing teaching to a client who is to undergo a colonoscopy for colon cancer screening. Which of the following information should the nurse provide A. "You should have nothing to eat or drink for 3 hours prior to the procedure" B. "You should drink the bowel preparation slowly to prevent nausea" C. "You will have no discomfort following the procedure" D. "You will need someone to drive you home after your procedure" - ANSD.) "You will need someone to drive you home after your procedure" Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the pt receives moderate sedation A nurse in the emergency department is caring for a client who has a traumatic brain injury (TBI). Which of the following assessment findings should the nurse recognize as a late manifestation of increased intracranial pressure (ICP) (select all that apply) A. Tachypnea B. Increased restlessness C. Bradycardia D. Asymmetric pupils E. Widened pulse pressure - ANS-Bradycardia -Asymmetric pupils -Widened pulse pressure A nurse in the ICU is caring for a client who is reporting heart palpitations. The nurse notes ventricular tachycardia on the ECG monitor. Which of the following actions should the nurse take A. Defibrillate the client B. Prepare the client for cardioversion C. Initiate CPR D. Administer digoxin - ANSB. Prepare the client for cardioversion cardioversion is a synchronized countershock that uses a pulse to help convert vtach back to sinus rhythm for a client who is STABLE AND RESPONSIVE A nurse is administering epinephrine IV to a client who is having an anaphylactic reaction. Which of the following findings should the nurse identify as a therapeutic response to the medication A. Hypoglycemia B. Thickened bronchial secretions C. Regular heart rate with hypotension D. Non itchy skin wheals - ANSD) Non itchy skin wheals A pt in anaphylactic shock can experience intensely itchy skin with wheals or hives that can merge to form large red blotches. Epi blocks the release of histamine and decreases erythema, angioedema, and hives A nurse is administering parenteral nutrition to a client who has a history of heart failure. Which of the following manifestations indicates to the nurse that the client is experiencing fluid overload A. hypotension B. flattened neck veins C. nocturia D. weight loss - ANSC C. sharp chest pain D. petechiae over lower extremities - ANSC. sharp chest pain A nurse is caring for a client who has end stage liver disease and an active upper GI bleed. After inserting an NG tube, which of the following findings should the nurse expect A. Bright red drainage B. Dark brown drainage C. Off white drainage D. Greenish yellow drainage - ANSA. Bright red drainage Red NG output indicates the client has an active upper GI bleed A nurse is caring for a client who has gastroenteritis with nausea and vomiting. Which of the following findings should the nurse identify as the most accurate indication of the client's fluid status A. The client's intake and output B. The client's skin turgor C. The client's blood pressure D. The client's daily weight - ANSD. The client's daily weight The most accurate indication of fluid loss is the measurement of the client's weight. *1 kg (2.2 lb) of weight loss= approx 1 L of fluid loss A nurse is caring for a client who has neutropenia following cyclosporine therapy. Which of the following actions should the nurse take? A. Monitor the client's vital signs every 8 hr B. Keep a designated blood pressure cuff in the client's room C. Inspect the client's mucous membranes daily D. Avoid the use of alcohol based hand sanitizers prior to client care - ANSB. Keep a designated blood pressure cuff in the client's room Designate equipment to keep in the client's room to limit exposing the equipment to micro-organisms from other clients. Patients with neutropenia have an increased risk for infection and sepsis due to a reduction in their leukocyte count A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (select all that apply) A. Monitor peripheral pulses in the affected extremity B. Position weights against the foot of the bed C. Adjust the prescribed weights every 24 hrs D. Examine the skin under the traction bood E. Assess the temperature of the affected extremity - ANSA, D, E -- A, closely monitor the neurovascular integrity. Circulation can be compromised from the fracture as well as the traction device D, monitor skin integrity at least every 8 hr E, Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure, paresthesia, and paralysis A nurse is caring for a client who is in the progressive stage of hypovolemic shock. Which of the following findings should the nurse expect A. Acidosis B. Bradycardia C. Hypertension D. Hypokalemia - ANSA. Acidosis In the progressive stage, compensatory mechanisms have failed. Decreased perfusion to the tissues results in anaerobic metabolism and the accumulation of metabolites, causing metabolic acidosis A nurse is caring for a client who is prescribed bedrest following a stroke. Which of the following interventions should the nurse implement to prevent foot drop A. Maintain the client's feet in plantar flexion B. Tuck the bed sheet tightly over the client's feet C. Support the feet with toes pointed upwards using padded splits D. Position and abductor pillow between the client's legs - ANSC. Support the feet with toes pointed upwards using padded splits Position the client's feet in a dorsiflexion position using a firm surface, such as a footboard, padded splints, or orthotics. The nurse should pad the splints to prevent areas of pressure on clients skin A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload A. Nasuea B. Hypothermia C. Dyspnea D. Bradycardia - ANSC Dyspnea Dyspnea is an indication of possible transfusion associated circulatory overload, leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate transfusion related acute lung injury to an anaphylactic response, which also causes wheezing, chest tightness, cyanosis, and low BP A nurse is caring for a client who is receiving brachytherapy. Which of the following actions should the nurse take? A. Limit visitation time to 2 hr per day, per visitor B. Wear a dosimeter film badge when caring for the client C. Open the door toe the client's room when visitors are present D. Double bag bed linens and remove them daily from the client's room - ANSB ) Wear a dosimeter film badge when caring for the client the badge does not protect the nurse form the effects of radiation, it does record the amount of individual exposure to the radiation A nurse is caring for a client who is receiving intermittent peritoneal dialysis. Which of the following actions should the nurse take A. Warm the dialysate in the microwave B. Weigh the client before and after each dialysis treatment C. Place the drainage bag at the level of the client's dialysis catheter D. Wear clean gloves when providing peritoneal catheter care - ANSB. Weigh the client before and after each dialysis treatment This determines the amount of fluid removed A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effectiveness of the treatment A. Sodium 165 mEq/L B. Potassium 5.2 mEq/L C. Urine specific gravity 1.020 D. Hct 62% - ANSC Urine specific gravity 1.020 Within the expected range of 1.005-1.030 A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which of the following actions should the nurse take to prepare the client for the procedure A. Advise the client that a chest xray will be necessary following the procedure B. Inform the client that the procedure requires general anesthesia C. Place the client in a supine position D. Instruct the client to take deep breaths during the procedure - ANSA. Advise the client that a chest xray will be necessary following the procedure pain mangement is important in the care of a client who has pancreatitis. Clients are most often started on opioid medication via PCA in the early stages of pancreatitis to mange pain A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan A. Provide the client with a means of communication B. Maintain the head of the client's bed in a flat position C. Suction the client's endotracheal tube every 4 hr D. Perform oral hygiene for the client every 8 hr - ANSA.) Provide the client with a means of communication Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse plan to take (select all that apply) A. Obtain pre-transfusion temperature B. Prime the IV tubing with lactated Ringer's C. Instruct an assistive personnel to monitor the client during the transfusion D. Verify the client's blood type with a second nurse E. Use a 20 gauge IV needle for venous access - ANSA, D, E A, complete assessment prior to transfusion D, verify identification, blood compatibility, and expiration of product with second nurse E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which of the following items is the priority for the nurse to have available in the client's room upon admission A. Obturator B. Hydrogen peroxide C. Sterile gloves D. Inner cannula - ANSA.) Obturator The obturator can be inserted in the stoma in the even of dislodgment or decannulation to maintain an airway until a new trach tube can be placed. For the first 72 hr following the insertion of a trach, dislodgement or decannulation is considered an emergency A nurse is preparing to obtain blood cultures from a client's central venous catheter (CVC). Which of the following actions should the nurse take when accessing the catheter A. Flush the lumen with heparin solution before each use B. Aspirate for blood return prior to each use C. Perform a 5 second scrub to the catheter hub before accessing the catheter D. Apply firm pressure to the syringe plunger when flushing the lumen - ANSB) Aspirate for blood return prior to each use A nurse is preparing to transfuse 1 unit of packed RBC to a client. Which of the following actions should the nurse take first A. Verify the label on the blood product with 2 client identifiers B. Check the client's medical record to verify the provider's prescription C. Flush the blood tubing with 0.9% sodium chloride D. Instruct the client to report itching or shortness of breath - ANSB) Check the client's medical record to verify the provider's prescription The greatest risk to this client is injury from a transfusion reaction, so the first action is to check the medical record to verify the providers order. This reduces the risk for client injury form receiving incompatible packed RBCs A nurse is providing discharge teaching to a client who has lithotripsy for calcium phosphate renal calculi. Which of the following instructions should the nurse give to the client A. Limit intake of animal protein to 6 oz per day B. Increase fluid intake to 1.5L/ day C. Expect pain in the kidneys and bladder D. Expect difficulty urinating for up to 1 week - ANSA. Limit intake of animal protein to 6 oz per day To prevent further kidney stones, the client should limit animal protein intake to 5 servings per week. Animal protein contains purine, which produces uric acid that can accumulate as stones in the kidney A nurse is providing discharge teaching to a client who is postoperative following glaucoma surgery. Which of the following instructions should the nurse include to prevent increased intraocular pressure A. "Avoid straining to have a bowel movement" B. "Avoid lying on your right side" C. "Avoid lifting objects that weigh more than 5 pounds" D. "Avoid sleeping with your head elevated" - ANSA Consume a diet high in fiber and fluids to prevent constipation and straining to have a bowel movement, which can increase intraocular pressure A nurse is providing discharge teaching to a client who was admitted to the medical surgical unit due to heart failure. Which of the following statements by the client indicates an understanding of the teaching A. "I will limit my dietary sodium intake to 4 grams per day" B. "I should weigh myself once a week" C. "I plan to wait 2 hours after eating to take my walk" D. "I will take my diuretic before going to bed at night" - ANSC To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in exercise -- A, limit sodium to 2-3g per day to prevent fluid retention in a heart healthy diet B, weigh daily! Report a weight gain of more than 1.4kg (3lb) in 1 day or more than 2.3 kg (5lb) per week D, take diuretics in the morning to avoid having to get up during the night to void A nurse is providing teaching about health promotion activities to an older adult client. Which of the following recommendations should the nurse include in the teaching A. "Maintain your dietary fat intake at 45% of your daily caloric intake" B. "Obtain 15 minutes of sunlight exposure 3 times per week" C. "Exercise for 30 minutes twice per week" D. "Decrease your fiber intake to less than 20 grams per day" - ANSB) "Obtain 15 minutes of sunlight exposure 3 times per week" Instruct the client to obtain at least 10-15 min of exposure to sunlight 2-3 times per week to ensure adequate vitamin D production A nurse is providing teaching to a client who has venous insufficiency. Which of the following statements by the client indicates an understanding of the teaching A. "I will wear my graduated compression stockings while sleeping" B. "I will elevate my legs for 10 minutes 3 times per day" C. "I will limit the time I spend sitting down during the day" D. "I will cross my legs at my knees when sitting" - ANSC) "I will limit the time I spend sitting down during the day" Avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis A nurse is providing teaching to a client who is undergoing radiation therapy and wants to go for a walk outside. Which of the following recommendations should the nurse include in the teaching? D. Hypoglycemia - ANSC. Potassium 3.2 mEq/L Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect A. 3.6 mg/dl B. 8 mg/dL C. 18.7 mg/dL D. 26 mg/dL - ANSD 26 mg/dL Normal range is 10-20, and elevated levels indicates renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues A nurse is reviewing the laboratory reports of a client who has cirrhosis. Which of the following results should the nurse report to the provider immediately A. BUN 22 mg/dL B. Sodium 134 mEq/L C. Platelet count 18,000 mm D. WBC 4,500 mm - ANSC) Platelet count 18,000 mm The greatest risk to this client is injury from hemorrhage, and 18,000 is critically lower than the range of 150,000-400,000. A level <20,000 is a critical value representing thrombocytopenia and the potential for spontaneous bleeding A nurse is reviewing the medical record of a client who is to undergo a surgical procedure. Which of the following findings indicates that the client is at risk for developing DVT A. BMI 38.6 B. History of asthma C. Use of glucosamine sulfate D. Hypothyroidism - ANSA. BMI 38.6 A BMI of 38.6 indicates the client is obese and is at a greater risk for developing DVT as a surgical complication A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which of the following instructions should the nurse include A. "Wait at least 5 minutes between puffs from the same inhaler" B. "Breathe in rapidly when inhaling the medication" C. "Clean the plastic inhaler cap weekly with cold water" D. "Shake the inhaler vigorously prior to use" - ANSD .) "Shake the inhaler vigorously prior to use" Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily A nurse is teaching the caregiver of a client who has mild alzheimer's disease about progression of the disease. Which of the following should the nurse include as a manifestation of moderate alzheimer's disease A. Short term memory loss B. misplacement of household items C. Episodes of wandering D. loss of mobility - ANSC) Episodes of wandering Wandering occurs in the moderate stage of AD A nurse on a medical surgical unit has received shift report for a group of clients. Which of the following interventions should the nurse plan to complete first A. Perform a dressing change on a client who is 24 hr postoperative following abdominal surgery and has sanguineous drainage on the dressing B. Replace an infiltrated IV for a client who has pneumonia and has scheduled IV antibiotics due in 30 minutes C. administer a prescribed opioid pain medication to a client who is reporting back pain as a 5 on a numeric pain scale of 0 to 10 D. Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min - ANSD) Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min Using the ABC approach, this is the priority. A RR of 7 indicates hypoventilation and can indicate respiratory failure or shock, especially in pt who is postop. A nurse on a medical unit is planning care for a client who has COPD. Which of the following actions should the nurse include in the plan A. Suction the client's airway every 4 hours B. Limit the client's fluid intake to control secretions C. Provide the client with a high protein diet D. Administer the client's bronchodilator following each meal - ANSC) Provide the client with a high protein diet COPD needs a diet high in protein and calories. They should eat freuqent, small meals and should avoid drinking fluids prior to or during meals A nurse on an ICU is caring for a client who has developed ventricular fibrillation. Which of the following actions is the nurses priority A. Defibrillate the client B. Apply oxygen for the client C. Provide chest compressions for the client D. Administer epinephrine to the client - ANSA. Defibrillate the client Vfib is a lethal rhythm, ventricles are quivering and has no cardiac output and must be defibrillated! If Vfib continues after one shock, then deliver CPR and airway management