Capstone ATI NCLEX Medical Surgical Assessment 1 Questions and Answers Guaranteed Pass., Exams of Nursing

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Capstone ATI NCLEX Medical Surgical

Assessment 1 Questions and Answers

Guaranteed Pass.

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" - Correct answer 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 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 - Correct answer A.) 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 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. D. Hct 62% - Correct answer C Urine specific gravity 1. Within the expected range of 1.005-1.

A nurse is monitoring the laboratory findings for a client who is postoperative 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, D. RBC 4.0 million - Correct answer C Platelets 80, platelet range is 150,000-400, 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 - Correct answer 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) 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 - Correct answer C 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 assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy

A. Hair loss on the scalp B. Sweating at the treatment site C. Altered taste sensations D. Intolerance to cold - Correct answer C Altered taste sensations Altered taste is a result of the release of metabolites by dead cells 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 - Correct answer A, 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 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 - Correct answer D 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 ECG strips for several clients. Which of the following images should the nurse identify as atrial fibrillation

(cannot insert pictures, read description) A. multiple irregular and variable waves at the baseline and irregular R to R intervals B. a rate of 140-180/min C. a tachycardia with no identifiable P wave and is determined to originate somewhere other than the ventricles. Rate between 100-280/min D. a P wave for every QRS, rate is 60-100/min - Correct answer A.) multiple irregular and variable waves at the baseline and irregular R to R intervals 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 - Correct answer A.) 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 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" - Correct answer A .) "Tell me how the changes to your leg make you feel" 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" - Correct answer 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 A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse A. Oxygen saturation 90% B. No response to verbal stimuli C. Occasional premature ventricular contractions (PVCs) D. Nausea - Correct answer 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 A nurse is reviewing the laboratory findings for a client who has heart failure 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 - Correct answer C. 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 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 - Correct answer A, 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 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 - Correct answer 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 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 - Correct answer A) Keep the client's room dark and quiet Meningitis often causes photophobia and phonophobia. Reduce stimuli 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 the nurse take A. Ask the client to exhale slowly B. Turn the client's head to the right C. Place the client in a semi fowlers position D. use aseptic technique - Correct answer D use aseptic technique aseptic= sterile prevents central line related blood infections when disconnecting and reconnecting the new set A nurse is educating an older adult client about immunizations. Which of the following immunizations should the nurse include in the recommendation for the client A. Recombinant herpes zoster B. Human papillomavirus C. Live attenuated influenza D. Varicella - Correct answer A) Recombinant herpes zoster herpes zoster= shingles Older adults can get either the live or recombinant herpes zoster immunization A nurse is caring fro a client who has continuous bladder irrigation following a transurthral resection of the prostate (TURP). Which of he following actions should the nurse take A. Place the indwelling urinary catheter tubing so it lies freely between the client's legs B. Irrigate the indwelling urinary catheter using sterile water

C. Subtract the amount of irrigation solution from the indwelling urinary catheter output D. Flush the indwelling urinary catheter with 30mL of irrigation solution to clear an obstruction - Correct answer C ) Subtract the amount of irrigation solution from the indwelling urinary catheter output Determine an accurate urinary output by subtracting the amount of irrigation solution from the total output in the urinary drainage bag 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 - Correct answer D) 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 assisting in selecting foods for lunch with a client who has diverticulosis. Which of the following foods should the nurse recommend as the best source of fiber A. 1 slice of rye bread B. 1/2 cup cooked navy beans C. 1/2 cup cooked asparagus D. 1/2 cup watermelon - Correct answer B) 1/2 cup cooked navy beans navy beans contain 5g of fiber per 1/2 cup 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" - Correct answer C) "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? 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" - Correct answer A) "Try to avoid sun exposure 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 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 - Correct answer 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 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 - Correct answer B) Aspirate for blood return prior to each use 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 - Correct answer 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. 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 - Correct answer 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 should avoid drinking fluids prior to or during meals 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 - Correct answer 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 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 - Correct answer C) Episodes of wandering Wandering occurs in the moderate stage of AD 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" - Correct answer C 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 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 - Correct answer C) 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 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 - Correct answer B) 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 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" - Correct answer A 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 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" - Correct answer B) "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- times per week to ensure adequate vitamin D production 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 - Correct answer 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 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 inflammatory 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 - Correct answer A. ) WBC count 14,000/mm

WBC count of 14,000 is above the expected range of 5,000-10,000. SIRS overwhelms 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 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 - Correct answer 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 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 - Correct answer 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 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 - Correct answer 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 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 - Correct answer -Bradycardia -Asymmetric pupils -Widened pulse pressure 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 - Correct answer A. Bright red drainage Red NG output indicates the client has an active upper GI bleed 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 - Correct answer 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 can indicate a malignant process and the provider should be notified. 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. B. History of asthma C. Use of glucosamine sulfate D. Hypothyroidism - Correct answer A. BMI 38. 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 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 - Correct answer B. 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 completing a preoperative assessment on a client who is scheduled for surgery in the morning. Which of the following findings should indicate to the nurse that the client is at risk for increased bleeding A. History of smoking B. Shellfish allergy C. Uses St John's wort

D. Takes a garlic supplement - Correct answer D. Takes a garlic supplement Garlic supplements increase the client's risk for bleeding due to garlic's ability to inhibit blood clotting by decreasing platelet aggregation A nurse is assessing a client who has a calcium level of 12.3 mg/dL. Which of the following findings should the nurse expect A. lethargy B. muscle spasms C. positive chvostek's sign D. shortened P-R interval - Correct answer A. lethargy 12.3 calcium indicates hypercalcemia (range is 9-10.5). 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 - Correct answer B. 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 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 - Correct answer 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 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 - Correct answer C. Metabolic acidosis 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 - Correct answer A. 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 - Correct answer 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

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 - Correct answer 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 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 - Correct answer D. 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 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 - Correct answer 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

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 - Correct answer B. 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 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 - Correct answer A. Advise the client that a chest xray will be necessary following the procedure chest X ray verifies that a pneumothorax or a mediastinal shift has not occurred A nurse is caring for a client who has developed a pulmonary embolus (PE). Which of the following assessment findings should the nurse expect A. bradycardia B. lethargy C. sharp chest pain D. petechiae over lower extremities - Correct answer C. sharp chest pain 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 - Correct answer A. 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

• Correct answer