MED SURG ATI CAPSTONE III CONCEPT
REVIEW GUIDE 2026 PATIENT SAFETY AND
CRITICAL THINKING STRATEGIES
◉ a nurse is caring for a female client in the ED who reports SOB and
pain in the lung area, she states that she started taking BC pills 3
weeks ago and that she smokes, her heart rate is 110/min, RR
40/min, and BP 140/80, her ABGs are pH 7.50, PaCO2 29, PaO2 60,
HCO3 20, SaO2 86%, what is the priority of nursing interventions.
Answer: administer oxygen via face mask
◉ a nurse is caring for a pt following repair of a fracture, what
finding should alert the nurse that the pt is experiencing
compartment syndrome?.
Answer: unrelieved pain, pallor, pulselessness, numbness, pins and
needles sensation, swelling, tightness of the effected extremity
◉ a nurse is administering a tap water enema to a pt who is
constipated, during the administration of the enema, the client
states he is having abdominal cramps, what action should the nurse
take to relieve the client's comfort.
Answer: lower the height of the solution container
,◉ a pt is diagnosed with left homonymous hemianopsia following a
stroke, what action should the nurse take?.
Answer: place the clients bedside table on the right side of the bed
◉ a nurse is caring for a pt who is at risk for shock, what finding is
the earliest indicator that this complication is developing?.
Answer: narrowing pulse pressure
◉ a nurse is assessing a client who has hypokalemia as a result of
n/v, and diarrhea, what finding should the nurse expect.
Answer: weak, irregular pulse
◉ a nurse is providing teaching for a client who has experienced an
acute episode of gastritis, what instruction should the nurse include
in the teaching?.
Answer: avoid drinking alcohol
◉ a nurse at an outpt surgery center is providing discharge teaching
to a pt an his spouse following surgical removal of a cataract, what
should the nurse include?.
Answer: the client should wear dark glasses while outdoors
◉ a nurse is assessing a pt who has a puncture wound on his foot,
what is a manifestation of acute osteomylitis?.
, Answer: localized erythema
◉ a nurse is monitoring a pt who had a cerebral aneurysm rupture,
what finding should the nurse identify as a manifestation of
increased intracranial pressure.
Answer: irritability
◉ when caring for a pt with a chest tube the nurse notes continuous
bubbling in the chest tube water seal chamber, what does this
indicate.
Answer: an air leak
◉ a nurse is an ED is caring for a client who had a seizure and
became unresponsive after stating she had a sudden, severe
headache, and vomiting, the pts vital signs are as follows: BP
198/110, pulse of 82/min, RR of 24m/min, temp of 100.8F, what
neuro disorders should the nurse suspect.
Answer: hemorrhagic stroke
◉ a nurse is caring for a pt who is 2hr postoperative following a
TURP, what assessment should be an indication of a postoperative
complication.
Answer: output of burgundy colored urine
REVIEW GUIDE 2026 PATIENT SAFETY AND
CRITICAL THINKING STRATEGIES
◉ a nurse is caring for a female client in the ED who reports SOB and
pain in the lung area, she states that she started taking BC pills 3
weeks ago and that she smokes, her heart rate is 110/min, RR
40/min, and BP 140/80, her ABGs are pH 7.50, PaCO2 29, PaO2 60,
HCO3 20, SaO2 86%, what is the priority of nursing interventions.
Answer: administer oxygen via face mask
◉ a nurse is caring for a pt following repair of a fracture, what
finding should alert the nurse that the pt is experiencing
compartment syndrome?.
Answer: unrelieved pain, pallor, pulselessness, numbness, pins and
needles sensation, swelling, tightness of the effected extremity
◉ a nurse is administering a tap water enema to a pt who is
constipated, during the administration of the enema, the client
states he is having abdominal cramps, what action should the nurse
take to relieve the client's comfort.
Answer: lower the height of the solution container
,◉ a pt is diagnosed with left homonymous hemianopsia following a
stroke, what action should the nurse take?.
Answer: place the clients bedside table on the right side of the bed
◉ a nurse is caring for a pt who is at risk for shock, what finding is
the earliest indicator that this complication is developing?.
Answer: narrowing pulse pressure
◉ a nurse is assessing a client who has hypokalemia as a result of
n/v, and diarrhea, what finding should the nurse expect.
Answer: weak, irregular pulse
◉ a nurse is providing teaching for a client who has experienced an
acute episode of gastritis, what instruction should the nurse include
in the teaching?.
Answer: avoid drinking alcohol
◉ a nurse at an outpt surgery center is providing discharge teaching
to a pt an his spouse following surgical removal of a cataract, what
should the nurse include?.
Answer: the client should wear dark glasses while outdoors
◉ a nurse is assessing a pt who has a puncture wound on his foot,
what is a manifestation of acute osteomylitis?.
, Answer: localized erythema
◉ a nurse is monitoring a pt who had a cerebral aneurysm rupture,
what finding should the nurse identify as a manifestation of
increased intracranial pressure.
Answer: irritability
◉ when caring for a pt with a chest tube the nurse notes continuous
bubbling in the chest tube water seal chamber, what does this
indicate.
Answer: an air leak
◉ a nurse is an ED is caring for a client who had a seizure and
became unresponsive after stating she had a sudden, severe
headache, and vomiting, the pts vital signs are as follows: BP
198/110, pulse of 82/min, RR of 24m/min, temp of 100.8F, what
neuro disorders should the nurse suspect.
Answer: hemorrhagic stroke
◉ a nurse is caring for a pt who is 2hr postoperative following a
TURP, what assessment should be an indication of a postoperative
complication.
Answer: output of burgundy colored urine
