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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: 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: 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: C Urine specific gravity 1.
- A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hour ago. Which of the following values indicates that the client has an increased risk for bleeding: 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: D Assist the client with quad coughing
- A nurse is caring for a client who is receiving a blood transfusion. Which of the
2 / following findings indicates that the client is experiencing transfusion-as- sociated circulatory overload: 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: 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): 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: D 26 mg/dale 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
4 / following actions should the nurse take? (select all that apply): 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 hour 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
- 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 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: D use aseptic technique aseptic= sterile
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- 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 herpes zoster= shingles
- A nurse is caring from a client who has continuous bladder irrigation
following a transurethral resection of the prostate (TURP). Which of he following actions should the nurse take: 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: 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: B) 1/2 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: C) "I will limit the time I spend sitting down during the day"
7 / client is experiencing fluid overload: 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: 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: C To promote exercise tolerance, the client should wait for 2 hour 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: C)
8 / 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: 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: 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: 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?: 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 the initial stages of systemic inflammatory response
10 / the nurse expect: A. Bright red drainage
- A nurse is educating a group of clients about menopause. Which of the
following information should the nurse include: 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: 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?: 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: D. Takes a garlic supplement
- 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
- 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: B. Prepare the client for cardioversion
- A nurse is providing discharge teaching to a client who has lithotripsy for calcium
11 / 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
- A nurse is reviewing the ABG results of a client who is receiving total par-
enteral 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: 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
- 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: C. Support the feet with toes pointed upwards using padded splits
- A nurse in a post anesthesia 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
- 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: D. The client's daily weight
