Capstone Med Surg Assessment 1 all answers correct; latest spring 2022/2023, Exams of Nursing

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Capstone Med Surg Assessment 1 all answers correct; latest

spring 2022/

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 Use electronic tablet computer, programmable speech generating device, alphabet board, pencil and paper, etc -- B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associated pneumonia. Turn the client q 2hr to prevent complications related to immobility C, assess the need to suction q 2-4 hr, but not perform routine suctioning. Base the need for suctioning on assessments, not a schedule. Unnecessary suctioning can cause bronco spasms and injury tracheal mucosa

D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated pneumonia 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% - ✅✅C Within the expected range of 1.005-1. -- A, sodium range is 136- B, potassium range is 3.5- D, Hct range is 37%-52% 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 - ✅✅C platelet range is 150,000-400, -- A, PT range is 11-12. B, aPTT range is 30-40 seconds D, RBC range is 4.2-6.1 million. A low RBC can indicate that bleeding has occurred, but it does not indicate that the client is at risk for bleeding 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 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 - ✅✅C 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, nausea can indicate an acute hemolytic transfusion reaction B, transfusion reactions include acute hemolytic, febrile, mild allergic, and anaphylactic

D, bradycardia is not an indication 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 - ✅✅C Altered taste is a result of the release of metabolites by dead cells -- A, client may have hair loss at the treatment site on the chest B, client might have skin changes, such as dryness and increased sensitivity D, avoid heat exposure

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 - ✅✅A, D, E -- A, complete assessment prior to transfusion B, prime tubing with a solution that does not cause hemolysis of PRBCs. No LR or 5% dextrose! C, nurse should remain with pt for first 15 minutes of 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 - ✅✅D 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 low BUN level can indicate malnutrition, malabsorption, liver disease, fluid overload, or nephrotic syndrome 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 - ✅✅A -- B, Vtach C, SVT D, normal sinus 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 - ✅✅A

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 -- B, used for trach care, but not priority C, sterile gloves for suctioning or for dressing change, but not priority D, inner cannula in case it needs to be replaced, but not priority 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

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 Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily -- A, wait at least 30 to 60 seconds between puffs of the medication. Wait 2-5 min between using different medications from separate inhalers B, breathe in slowly and deeply to distribute the medication evenly throughout the bronchiole tissue. If the spacer makes a whistling noise, they are breathing too rapidly C, clean the spacer weekly and the plastic cap of the inhaler at least once daily by rising them in warm water 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 Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the pt receives moderate sedation -- A, begin a clear diet the day before the procedure. The pt should have nothing to eat or drink for 4-6 hr prior to the procedure B, drink the bowel prep quickly to minimize nausea C, it is typical to have cramping and a feeling of fullness after a colonoscopy d/t the instillation of air into the bowel during the 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

A. Oxygen saturation 90% B. No response to verbal stimuli C. Occasional premature ventricular contractions (PVCs) D. Nausea - ✅✅B 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 - ✅✅C Loop diuretics remove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium. Monitor for dysrhythmias -- A, monitor for hyponatremia (sodium < 136)

B, furosemide can cause metabolic alkalosis, monitor for cramping, twicthing, and increased HR D, furosemide can cause hyperglycemia 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 -- A, closely monitor the neurovascular integrity. Circulation can be compromised from the fracture as well as the traction device B, weights should hang freely away from the foot of the bed to promote proper traction and healing. Hanging freely provides counter traction that diminishes muscle spasms

C, Buck's is a short term treatment with weights ranging 2.3-4.5 kg (5- 10lb). Nurse does not adjust the weight without a prescription from the provider 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 - ✅✅A 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 --

B, learning and memory are loss impaired, so it is unrealistic to expect this pt to remember instructions long term. Caregiver should remove the knobs or controls on the stove so the pt cant turn it on C, at a high risk for falls, rugs increase risk for slipping D, loss of cognition and recognition of environment. Keeping the room dark will further decrease the ability of the client to gain their bearings and places the client at risk for falls. Use a night-light 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 Meningitis often causes photophobia and phonophobia. Reduce stimuli -- B, risk of thrombotic or embolic complications, perform a vascular assessment at least every 4 hours or more often as needed

C, head of bed should be elevated to 30 degrees at all times. Remain on bedrest until activity is tolerated D, meningitis needs droplet precautions for the first 24 hr of antibiotic therapy to prevent transmission. If viral meningitis is confirmed diagnosis, the precautions may be removed 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 - ✅✅D aseptic= sterile prevents central line related blood infections when disconnecting and reconnecting the new set -- A, ask pt to perform the valsalva maneuver by inhaling, holding their breath, and bearing down to prevent any air from entering the catheter when disconnecting and reconnecting the new set

B, turn clients head to the left to facilitate access to the clients catheter, which is located in the right subclavian vein C, the client should lie flat to ensure the catheter exit site is at or below the level of the heart 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 - ✅✅A herpes zoster= shingles Older adults can get either the live or recombinant herpes zoster immunization -- B, the HPV vaccine is recommended only for pt < 26 years old C, live attenuated influenza vaccine is recommended only for pt < years old. Older adults should receive inactivated or recombinant influenza immunization

D, varicella is recommended only for pt born after 1980 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 - ✅✅C Determine an accurate urinary output by subtracting the amount of irrigation solution from the total output in the urinary drainage bag -- A, fasten the drainage tube securely to the client's thigh B, use sterile 0.9% sodium chloride irrigation, which is an isotonic solution, for bladder irrigation. Sterile water is hypotonic and can be absorbed if used as an irrigation solution, causing fluid shifts and dilutional hyponatremia

D, irrigate with 50 mL of irrigation solution to free an obstruction in the catheter 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 - ✅✅D 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. This finding indicates a therapeutic response to the epi -- A, hyperglycemia is an adverse effect of epi. Hypoglycemia from the administration of epi does not indicate a therapeutic response to the medication B, a client in anaphylactic shock can have an increase in congestion, tongue and larynx swelling, and increased mucus production.

Decreased bronchial secretions and a clear airway indicate and therapeutic response to epi C, a client in anaphylactic shock can have hypotension and a rapid, weak, irregular pulse from vasodilation of vessels and extensive capillary leaks. Absence of hypotension and an elevated HR indicate an therapeutic response to epi 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 - ✅✅B navy beans contain 5g of fiber per 1/2 cup -- A, 1 slice of rye bread has 1g of fiber C, 1/2 cup of asparagus has 1g fiber D, 1/2 cup of watermelon has 0.3 g fiber

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" - ✅✅C Avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis -- A, wear graduated compression stockings during the day and evening, remove stockings at bedtime B, elevate legs for at least 20 minutes 4 or 5 times per day. When lying down, elevate the legs above the level of their heart D, do not cross legs when sitting 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" - ✅✅A 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 -- B, do not remove any temporary ink markings when cleaning the skin until the entire course of radiation is complete C, apply only lotions that he provider prescribes. Chemical agents in sunscreen can cause irritation to the radiated skin D, wear loose fitting clothing over the treated area of skin. No buckles, belts, straps, or anything that binds or rubs the skin at the site 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 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 -- B, creatinine kinase MB elevates when there is injury to brain tissue, myocardial muscle, or skeletal muscle C, elevated cholesterol increases the risk for cardiovascular disease, but does not diagnose an MI D, this is within the expected reference range 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 - ✅✅B -- A, flush the lumen of any CVC with 0.9% sodium chloride. The nurse can flush an implanted port with 5mL heparin 10 units / mL to prevent clots C, 15 second scrub D, apply slow, even pressure to the syringe plunger to flush the lumen, and immediately stop if there is resistance. Use a 10mL syringe when flushing central catheters 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 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 - ✅✅C 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, do not suction COPD on a routine basis, only suction as necessary to clear secretions and maintain a patent airway