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CAPSTONE ATI NCLEX MEDICAL SURGICAL
ASSESSMENT 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 - ANSWER - D .) "Shake the inhaler vigorously prior to use" 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 - ANSWER - A.) Provide the client with a means of communication 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 - ANSWER - C Urine specific gravity 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 - ANSWER - C Platelets 80, 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 - ANSWER - D Assist the client with 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 - ANSWER - C Dyspnea 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 - ANSWER - C Altered taste sensations 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) - ANSWER - A, D, E A, complete assessment prior to transfusion
items is the priority for the nurse to have available in the client's room upon admission - ANSWER - A.) Obturator 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 - 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 - ANSWER - D.) "You will need someone to drive you home after your procedure" A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse - ANSWER - B) No response to verbal stimuli 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 - ANSWER - C. Potassium 3.2 mEq/L 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) - 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
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 - 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 - ANSWER - D) Non itchy skin wheals 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 - ANSWER - B) 1/ cup cooked navy beans 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 - ANSWER - C) "I will limit the time I spend sitting down during the day"
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? - ANSWER - A) "Try to avoid sun exposure by waiting until after sunset to go outdoors" 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) - ANSWER - A ) Increased troponin 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 - 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 - ANSWER - D) Assess a client who is 4hr postoperative following thoracic surgery and has a respiratory rate of 7/min
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 - ANSWER - C) Episodes of wandering 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 - ANSWER - C To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in exercise 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 - ANSWER - C) Platelet count 18,000 mm A nurse is preparing to transfuse 1 unit of packed RBC to a client. Which of the following actions should the nurse take first
- ANSWER - B) Check the client's medical record to verify the provider's prescription
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 - 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 - ANSWER - B) "Obtain 15 minutes of sunlight exposure 3 times per week" 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? - ANSWER - C) Gabapentin 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
manifestation of increased intracranial pressure (ICP) (select all that apply) - 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 - ANSWER - A. Bright red drainage A nurse is educating a group of clients about menopause. Which of the following information should the nurse include - ANSWER - C) Vaginal bleeding after 1 year without 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 - ANSWER
- A. BMI 38. A nurse is caring for a client who has neutropenia following cyclosporine therapy. Which of the following actions should the
nurse take? - ANSWER - B. Keep a designated blood pressure cuff in the client's room 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 - ANSWER - D. Takes a garlic supplement A nurse is assessing a client who has a calcium level of 12. mg/dL. Which of the following findings should the nurse expect
- ANSWER - A. lethargy 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 - ANSWER - B. Prepare the client for cardioversion 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 - ANSWER - A. Limit intake of animal protein to 6 oz per day
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 - ANSWER - D. The client's daily weight The most accurate indication of fluid loss is the measurement of the client's weight. 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 - ANSWER - B. CD4 T cell count 175 A nurse is caring for a client who is receiving intermittent peritoneal dialysis. Which of the following actions should the nurse take - ANSWER - B. Weigh the client before and after each dialysis treatment 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 - ANSWER - A. Advise the client that a chest xray will be necessary following the procedure
A nurse is caring for a client who has developed a pulmonary embolus (PE). Which of the following assessment findings should the nurse expect - 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 - ANSWER - A. Defibrillate the client
