ATI CAPSTONE-MED SURG-ASSESSEMENT 1 COMPLETE ASSESSMENT SOLUTION WITH RATIONALED ANSWERS 2021.

ATI CAPSTONE-MED SURG-ASSESSEMENT 1 COMPLETE ASSESSMENT SOLUTION WITH RATIONALED ANSWERS 2021. 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 decannu- lation 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 11. 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 12. 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" 5 / 29 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 13. 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 14. A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse 6 / 29 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 15. 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