Notesale: Turn your study into money

Document Preview

Extracts from the notes are below, to see the PDF you'll receive please use the links above

---

CAPSTONE ATI NCLEX MEDICAL
SURGICAL ASSESSMENT 1 WITH
COMPREHENSIVE CORRECT ANSWERS
...
Which of the following instructions should the nurse include

A
...
"Breathe in rapidly when inhaling the medication"
C
...
"Shake the inhaler vigorously prior to use" - CorreCt Answers -D
...

The nurse notes ventricular tachycardia on the ECG monitor
...
Defibrillate the client
B
...
Initiate CPR
D
...
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
...
Limit intake of animal protein to 6 oz per day
B
...
5L/ day
C
...
Expect difficulty urinating for up to 1 week - CorreCt Answers -A
...
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
...
25, a bicarbonate of 18
mEq/L, and PaCO2 of 43 mm Hg
...
Metabolic alkalosis
B
...
Metabolic acidosis
D
...
Metabolic acidosis

A nurse is caring for a client who is in the progressive stage of hypovolemic
shock
...
Acidosis
B
...
Hypertension
D
...
Acidosis
In the progressive stage, compensatory mechanisms have failed
...

Which of the following interventions should the nurse implement to
prevent foot drop

A
...
Tuck the bed sheet tightly over the client's feet
C
...
Position and abductor pillow between the client's legs - CorreCt Answers
-C
...
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
...
Clear drainage on the surgical dressing
B
...
Reports discomfort when log rolling
D
...
Clear
drainage on the surgical dressing

Clear fluid on or around the surgical dressing following a laminectomy is an
indication of CSF leak
...
Which of the following findings should the nurse identify as the
most accurate indication of the client's fluid status

A
...
The client's skin turgor
C
...
The client's daily weight - CorreCt Answers -D
...


*1 kg (2
...
Which of
the following laboratory values should the nurse report to the provider
immediately

A
...
CD4 T cell count 175
C
...
WBC count 4,8000 - CorreCt Answers -B
...
This indicates
the client is at greatest risk for infection
A nurse is planning care for a client who is receiving mechanical
ventilation
...
Provide the client with a means of communication
B
...
Suction the client's endotracheal tube every 4 hr
D
...
)
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
...
Sodium 165 mEq/L
B
...
2 mEq/L
C
...
020

D
...
020
Within the expected range of 1
...
030

A nurse is monitoring the laboratory findings for a client who is
postoperative following a total hip arthroplasty 6 hr ago
...
PT 11
...
aPTT 35 seconds
C
...
RBC 4
...
Which of the following interventions is the nurse's
priority while caring for this client

A
...
Pad pressure points at the edges of the client's cervical collar
C
...
Assist the client with quad coughing - CorreCt Answers -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
...
Which of
the following findings indicates that the client is experiencing transfusionassociated circulatory overload

A
...
Hypothermia
C
...
Bradycardia - CorreCt Answers -C Dyspnea
Dyspnea is an indication of possible transfusion associated circulatory
overload, leading to hypertension, bounding pulses, and confusion
...
Which of the following indicates an adverse
effect of the therapy

A
...
Sweating at the treatment site
C
...
Intolerance to cold - CorreCt Answers -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
...
Obtain pre-transfusion temperature
B
...
Instruct an assistive personnel to monitor the client during the
transfusion
D
...
Use a 20 gauge IV needle for venous access - CorreCt Answers -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
...
3
...
8 mg/dL
C
...
7 mg/dL
D
...
Which of the following
images should the nurse identify as atrial fibrillation

(cannot insert pictures, read description)

A
...
a rate of 140-180/min

C
...
Rate between 100-280/min

D
...
)
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
...
Obturator
B
...
Sterile gloves
D
...
) 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
...
Which of the following statements should the
nurse use to assess how the client is coping with this change in their body
image

A
...
"What potential changes do you think you'll need to make when doing
your job"
C
...
"What are some possible issues that you foresee when completing selfmanagement tasks" - CorreCt Answers -A
...
Which of the following
information should the nurse provide

A
...
"You should drink the bowel preparation slowly to prevent nausea"
C
...
"You will need someone to drive you home after your procedure" CorreCt Answers -D
...
Which of the following findings requires immediate
intervention by the nurse

A
...
No response to verbal stimuli
C
...
Nausea - CorreCt Answers -B) No response to verbal stimuli
using urgent vs non-urgent approach, this is the priority
...
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
...
Sodium 142 mEq/L
B
...
Potassium 3
...
Hypoglycemia - CorreCt Answers -C
...
2 mEq/L
Loop diuretics remove excessive extracellular fluid through the kidneys,
causing an increased excretion of potassium
...
Which of the
following actions should the nurse take? (select all that apply)

A
...
Position weights against the foot of the bed
C
...
Examine the skin under the traction bood
E
...
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
...
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
...
Lock doors leading to stairways
B
...
Place a throw rug in front of the toilet
D
...
Which
of the following interventions should the nurse include in the plan

A
...
Perform a vascular assessment for the client every 6 hr
C
...
Place the client on contact precautions - CorreCt Answers -A) Keep the
client's room dark and quiet
Meningitis often causes photophobia and phonophobia
...
Which reconnecting a new intravenous infusion administration
set, which of the following actions should the nurse take

A
...
Turn the client's head to the right
C
...
use aseptic technique - CorreCt Answers -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
...
Recombinant herpes zoster
B
...
Live attenuated influenza
D
...
Which of he
following actions should the nurse take

A
...
Irrigate the indwelling urinary catheter using sterile water
C
...
Flush the indwelling urinary catheter with 30mL of irrigation solution to
clear an obstruction - CorreCt Answers -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
...
Hypoglycemia
B
...
Regular heart rate with hypotension
D
...
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
...
1 slice of rye bread
B
...
1/2 cup cooked asparagus
D
...

Which of the following statements by the client indicates an understanding
of the teaching

A
...
"I will elevate my legs for 10 minutes 3 times per day"
C
...
"I will cross my legs at my knees when sitting" - CorreCt Answers -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
...
"Try to avoid sun exposure by waiting until after sunset to go outdoors"
B
...
"Protect exposed skin with an over the counter sunscreen"
D
...
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
...
Increased troponin
B
...
Cholesterol 300 mg/dL
D
...
2 mg/dL - CorreCt Answers -A ) Increased troponin
Troponin is a myocardial muscle protein released into the blood stream as a
result of injury to the heart muscle
...
Which of the following actions should the nurse take when
accessing the catheter

A
...
Aspirate for blood return prior to each use
C
...
Apply firm pressure to the syringe plunger when flushing the lumen CorreCt Answers -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
...
Perform a dressing change on a client who is 24 hr postoperative
following abdominal surgery and has sanguineous drainage on the dressing

B
...
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
...
A RR of 7 indicates
hypoventilation and can indicate respiratory failure or shock, especially in
pt who is postop
...

Which of the following actions should the nurse include in the plan

A
...
Limit the client's fluid intake to control secretions
C
...
Administer the client's bronchodilator following each meal - CorreCt
Answers -C) Provide the client with a high protein diet
COPD needs a diet high in protein and calories
...
Which of the following manifestations indicates to the
nurse that the client is experiencing fluid overload

A
...
flattened neck veins
C
...
weight loss - CorreCt Answers -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
...
Short term memory loss
B
...
Episodes of wandering
D
...
Which of the following
statements by the client indicates an understanding of the teaching

A
...
"I should weigh myself once a week"
C
...
"I will take my diuretic before going to bed at night" - CorreCt Answers 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
...
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
...
BUN 22 mg/dL
B
...
Platelet count 18,000 mm
D
...
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
...
Verify the label on the blood product with 2 client identifiers
B
...
Flush the blood tubing with 0
...
Instruct the client to report itching or shortness of breath - CorreCt
Answers -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
...
Which of the following instructions should the
nurse include to prevent increased intraocular pressure

A
...
"Avoid lying on your right side"
C
...
"Avoid sleeping with your head elevated" - CorreCt Answers -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
...
"Maintain your dietary fat intake at 45% of your daily caloric intake"
B
...
"Exercise for 30 minutes twice per week"
D
...
Which of the following
medications should the nurse administer to treat the client's pain?

A
...
Cyclobenzaprine
C
...
Lidocaine - CorreCt Answers -C) Gabapentin
phantom limb pain is a type of neuropathic pain resulting from damage to
peripheral and central nervous system pathways
...
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
...
Platelets 110,000/ mm
C
...
C reactive protein 2
...
) WBC count
14,000/mm
WBC count of 14,000 is above the expected range of 5,000-10,000
...

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
...
Limit visitation time to 2 hr per day, per visitor
B
...
Open the door toe the client's room when visitors are present
D
...
Which of the following interventions should the nurse
include in the plan of care

A
...
Administer opioid medications via a PCA
C
...
Administer hypotonic IV fluids - CorreCt Answers -B) Administer opioid
medications via a PCA
pain mangement is important in the care of a client who has pancreatitis
...
Which of the following prescriptions should the nurse anticipate
for an aPTT of 110 seconds

A
...
Stop the heparin infusion
C
...
Administer atropine to the client - CorreCt Answers -B) Stop the heparin
infusion

Therapeutic range of aPTT for client on heparin is 1
...
5 times the normal
value
...
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)
...
Tachypnea
B
...
Bradycardia
D
...
Widened pulse pressure - CorreCt Answers --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
...
Bright red drainage
B
...
Off white drainage
D
...
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
...
Limit exercise to 30 min, one to two times a week to reduce fatigue
B
...
Vaginal bleeding after 1 year without menses should be reported to the
provider
D
...
Vaginal bleeding after 1 year can indicate
menopause has occurred, however, it can indicate a malignant process and
the provider should be notified
...
Which of the following findings indicates that the client
is at risk for developing DVT

A
...
6
B
...
Use of glucosamine sulfate
D
...
BMI 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
...
Monitor the client's vital signs every 8 hr
B
...
Inspect the client's mucous membranes daily
D
...
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
...
Which of the following findings
should indicate to the nurse that the client is at risk for increased bleeding

A
...
Shellfish allergy
C
...
Takes a garlic supplement - CorreCt Answers -D
...
3 mg/dL
...
lethargy
B
...
positive chvostek's sign
D
...
lethargy

12
...
5)
...
Which of the following actions should the nurse take

A
...
Weigh the client before and after each dialysis treatment
C
...
Wear clean gloves when providing peritoneal catheter care - CorreCt
Answers -B
...

Which of the following actions should the nurse take to prepare the client
for the procedure

A
...
Inform the client that the procedure requires general anesthesia
C
...
Instruct the client to take deep breaths during the procedure - CorreCt
Answers -A
...

Which of the following assessment findings should the nurse expect

A
...
lethargy
C
...
petechiae over lower extremities - CorreCt Answers -C
...
Which of the following actions is the nurses priority

A
...
Apply oxygen for the client
C
...
Administer epinephrine to the client - CorreCt Answers -A

---