- Capstone ATI NCLEX Medical Surgical Assessment 1 all answers correct latest spring 2024, Exams of Medicine

Download - Capstone ATI NCLEX Medical Surgical Assessment 1 all answers correct latest spring 2024 and more Exams Medicine in PDF only on Docsity! 1 / 18 - Capstone ATI NCLEX Medical Surgical Assessment 1 all answers correct latest spring 2024 1. 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": D .) "Shake the inhaler vigorously prior to use" Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily 2. 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: A.) Provide the client with a means of communication Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc 3. A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effective- ness of the treatment A. Sodium 165 mEq/L B. Potassium 5.2 mEq/L 2 / 18 C. Urine specific gravity 1.020 D. Hct 62%: C Urine specific gravity 1.020 Within the expected range of 1.005-1.030 4. A nurse is monitoring the laboratory findings for a client who is postoper- ative following a total hip arthroplasty 6 hr ago. Which of the following values indicates that the client has an increased risk for bleeding A. PT 11.5 seconds B. aPTT 35 seconds C. Platelets 80,000 D. RBC 4.0 million: C Platelets 80,000 platelet range is 150,000-400,000 5. A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle crash. Which of the following interventions is the nurse's priority while caring for this client A. Change the client's position every 2 hours B. Pad pressure points at the edges of the client's cervical collar C. Palpate the client's abdomen for bladder distention D. Assist the client with quad coughing: D Assist the client with quad coughing The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing) 6. 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-as- sociated circulatory overload A. Nasuea B. Hypothermia 5 / 18 B. Hydrogen peroxide C. Sterile gloves D. Inner cannula: A.) Obturator The obturator can be inserted in the stoma in the even of dislodgment or decannu- lation 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 12. A nurse is caring for a client who had a below the knee amputation due to a traumatic injury 2 days ago. Which of the following statements should the nurse use to assess how the client is coping with this change in their body image A. "Tell me how the changes to your leg make you feel" B. "What potential changes do you think you'll need to make when doing your job" C. "Let's discuss how you can adjust once you have a prosthesis" D. "What are some possible issues that you foresee when completing self-management tasks": A .) "Tell me how the changes to your leg make you feel" 13. 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": D.) "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 14. A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse 6 / 18 A. Oxygen saturation 90% B. No response to verbal stimuli C. Occasional premature ventricular contractions (PVCs) D. Nausea: B) No response to verbal stimuli using urgent vs non-urgent approach, this is the priority. During moderate sedation, the pt should be able to provide a response to questions and commands. No response to verbal stimuli can indicate a loss or consciousness or oversedation 15. A nurse is reviewing the laboratory findings for a client who has heart fail- ure and is taking furosemide. The nurse should identify which of the following findings as an adverse effect of the medication A. Sodium 142 mEq/L B. Metabolic acidosis C. Potassium 3.2 mEq/L D. Hypoglycemia: C. Potassium 3.2 mEq/L Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias 16. 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: A, D, E -- 7 / 18 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, pulse- lessness, pressure, paresthesia, and paralysis 17. A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer's disease. Which of the following instructions should the nurse include in the teaching A. Lock doors leading to stairways B. Instruct the client not to use the stove C. Place a throw rug in front of the toilet D. Provide a darkened room for the client to sleep: A) Lock doors leading to stairways This pt is at an increased risk for falls d/t difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease 18. A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan A. Keep the client's room dark and quiet B. Perform a vascular assessment for the client every 6 hr C. Maintain the head of the client's bed at 15 degrees at all times D. Place the client on contact precautions: A) Keep the client's room dark and quiet Meningitis often causes photophobia and phonophobia. Reduce stimuli 19. A nurse is caring for a client who has a right subclavian central venous catheter. Which reconnecting a new intravenous infusion administration set, which of the following actions should 10 / 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 25. 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 recommen- dations should the nurse include in the teaching? A. "Try to avoid sun exposure by waiting until after sunset to go outdoors" B. "Gently was the irradiated area to remove the markings before going outside" C. "Protect exposed skin with an over the counter sunscreen" D. "Wear form sitting clothing when going outside": A) "Try to avoid sun expo- sure by waiting until after sunset to go outdoors" Protect the skin from exposure to sunlight during treatment and for 1 year after the last treatment. Stay in the shade, go outside in the early morning or evening to avoid the more intense sun rays to allow the pt to stay outside for a longer period 26. 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: A ) 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 27. 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 11 / 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: B) Aspirate for blood return prior to each use 28. 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: D) 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. 29. 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: C) Provide the client with a high protein diet COPD needs a diet high in protein and calories. They should eat freuqent, small meals and 12 / should avoid drinking fluids prior to or during meals 30. 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: C when the client is recumbent, the extracellular fluid enters the vascular system and increases the blood volume filtering through the kidneys, which increases urine production -- A, hypertension indicates fluid overload in a pt with heart failure B, distended neck veins indicates fluid overload in a pt with heart failure D, acute weight gain is the most reliable indicator of fluid volume overload in a client who has heart failure 31. 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: C) Episodes of wandering Wandering occurs in the moderate stage of AD 32. 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 15 / 37. A nurse is caring for a client who has an above the knee amputation related to trauma and is experiencing phantom limb pain. Which of the following medications should the nurse administer to treat the client's pain? A. Meloxicam B. Cyclobenzaprine C. Gabapentin D. Lidocaine: C) Gabapentin phantom limb pain is a type of neuropathic pain resulting from damage to peripheral and central nervous system pathways. Gabapentin is an anticonvulsant medication that helps treat neuropathic pain 38. A nurse is reviewing the laboratory findings for a client who has a urinary tract infection. Which of the following laboratory findings should the nurse identify as an indication the client is in the initial stages of systemic inflam- matory response syndrome (SIRS)? A. WBC count 14,000/mm B. Platelets 110,000/ mm C. Lactic acid 19 mg/dL D. C reactive protein 2.8 mg/L: A. ) WBC count 14,000/mm WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS over- whelms the body's defenses, resulting in a widespread inflammation. WBCs might increase initially, but depending on the bone marrow's ability to produce neutrophils and WBCs, the WBC count can become extremely low 39. 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 16 / 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: B ) 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 40. A nurse is panning care for a client who has been newly diagnosed with acute pancreatitis. Which of the following interventions should the nurse include in the plan of care A. Encourage liquid nutritional supplements B. Administer opioid medications via a PCA C. Assess for signs of hypercalcemia D. Administer hypotonic IV fluids: B) Administer opioid medications via a PCA 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 41. A nurse is reviewing the current laboratory findings for a client who has a pulmonary embolism and is receiving heparin therapy by continuous IV infusion. Which of the following prescriptions should the nurse anticipate for an aPTT of 110 seconds A. Increase the rate of the heparin infusion B. Stop the heparin infusion C. Administer vitamin K to the client D. Administer atropine to the client: B) Stop the heparin infusion Therapeutic range of aPTT for client on heparin is 1.5-2.5 times the normal value. A value greater than 2.5 times the expected reference range of 20-40 seconds is critical! If the aPTT is > 100 seconds, anticipate a prescription to stop or decrease the heparin infusion rate 42. 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) 17 / A. Tachypnea B. Increased restlessness C. Bradycardia D. Asymmetric pupils E. Widened pulse pressure: -Bradycardia -Asymmetric pupils -Widened pulse pressure 43. 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: A. Bright red drainage Red NG output indicates the client has an active upper GI bleed 44. A nurse is educating a group of clients about menopause. Which of the following information should the nurse include A. Limit exercise to 30 min, one to two times a week to reduce fatigue B. Hormone therapy (HT) is no longer used because of the risk of cancer C. Vaginal bleeding after 1 year without menses should be reported to the provider D.The use of complementary therapies to treat hot flashes should be avoided- : C) Vaginal bleeding after 1 year without menses should be reported to the provider Immediately report to the provider about any vaginal bleeding that occurs 1 year after menses have stopped. Vaginal bleeding after 1 year can indicate menopause has occurred, however, it 20 / 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: A. 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 51. A nurse is reviewing the ABG results of a client who is receiving total parenteral nutrition. The nurse notes a pH of 7.25, a bicarbonate of 18 mEq/L, and PaCO2 of 43 mm Hg. Which of the following acid base imbalances is the client experiencing A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis: C. Metabolic acidosis 52. 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: A. Acidosis In the progressive stage, compensatory mechanisms have failed. Decreased per- fusion to the tissues results in anaerobic metabolism and the accumulation of metabolites, causing metabolic acidosis 53. 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 21 / 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: C. 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 54. A nurse in a postanesthesia care unit is performing a postoperative as- sessment 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: A. 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 55. 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: D. The client's daily weight 22 / 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 56. A nurse is reviewing laboratory reports for a client who has HIV. Which of the following laboratory values should the nurse report to the provider immediately A. Positive enzyme linked immunosorbent assay (ELISA) test B. CD4 T cell count 175 C. Positive western blot test D. WBC count 4,8000: B. CD4 T cell count 175 A CD4 cell count of < 200 indicates the client is severely immunocompromised and is in stage 3 of the disease (AIDS). This indicates the client is at greatest risk for infection 57. 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: B. Weigh the client before and after each dialysis treatment This determines the amount of fluid removed 58. 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