ATI Capstone Med Surg
a nurse is reviewing the ABG results of a client who the provider suspects has
metabolic acidosis. what would the nurse expect to see - Answer pH below 7.35
a pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound (S3),
what should the nurse anticipate as the cause of these s/s - Answer HF
a nurse is administering potassium chloride elixer 40mEq divided into 2 equal doses
every 12 hours, available is 6.7 mEq/5mL. how many mL should the nurse administer
per dose? - Answer 30mL
a nurse is caring for a pt in the ED who was just admitted with chest pain, possible
acute coronary syndrome. what should the nurse do first? - Answer administer
sublingual nitroglycerin
(treat chest pain to reduce cardiac tissue damage)
a nurse is caring for pt who is experiencing ventricular tachycardia with a pulse, the
RRT is at the bedside. what electrical intervention should be used to correct this
dysrhythmia? - Answer synchronized cardioversion
(tx for afib, SVT, and v tach with a pulse)
a nurse is caring for an adult pt who is experiencing delayed wound healing, which of
the following interventions should the nurse take? - Answer monitor serum albumin
levels and notify provider if below 3.5g/dL
(lack of protein increases the risk for a delay in wound healing and infection)
a nurse is teaching a client who has pre-dialysis ESKD about diet, what should be
included? - Answer reduce intake of foods high in potassium
(potassium clearance is impaired in ESKD)
a nurse is caring for a client who has T1DM, the nurse misread the client's morning BG
level as 210mg/dL, instead of 120mg/dL and administered the insulin dose appropriate
for a reading over 200mg/dL before the client's breakfast, what action is the nurse's
priority? - Answer monitor the client for hypoglycemia
a nurse is planning care for a pt who has a new diagnosis of DI, which of the following
interventions should the nurse include in the plan of care? - Answer check urine specific
gravity
a nurse is caring for a pt admitted with wheezing and coughing due to an allergic
reaction to a newly prescribed medication, what medication should be administered
first? - Answer albuterol 3mL via nebulizer
, ATI Capstone Med Surg
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
a nurse is reviewing the ABG results of a client who the provider suspects has
metabolic acidosis. what would the nurse expect to see - Answer pH below 7.35
a pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound (S3),
what should the nurse anticipate as the cause of these s/s - Answer HF
a nurse is administering potassium chloride elixer 40mEq divided into 2 equal doses
every 12 hours, available is 6.7 mEq/5mL. how many mL should the nurse administer
per dose? - Answer 30mL
a nurse is caring for a pt in the ED who was just admitted with chest pain, possible
acute coronary syndrome. what should the nurse do first? - Answer administer
sublingual nitroglycerin
(treat chest pain to reduce cardiac tissue damage)
a nurse is caring for pt who is experiencing ventricular tachycardia with a pulse, the
RRT is at the bedside. what electrical intervention should be used to correct this
dysrhythmia? - Answer synchronized cardioversion
(tx for afib, SVT, and v tach with a pulse)
a nurse is caring for an adult pt who is experiencing delayed wound healing, which of
the following interventions should the nurse take? - Answer monitor serum albumin
levels and notify provider if below 3.5g/dL
(lack of protein increases the risk for a delay in wound healing and infection)
a nurse is teaching a client who has pre-dialysis ESKD about diet, what should be
included? - Answer reduce intake of foods high in potassium
(potassium clearance is impaired in ESKD)
a nurse is caring for a client who has T1DM, the nurse misread the client's morning BG
level as 210mg/dL, instead of 120mg/dL and administered the insulin dose appropriate
for a reading over 200mg/dL before the client's breakfast, what action is the nurse's
priority? - Answer monitor the client for hypoglycemia
a nurse is planning care for a pt who has a new diagnosis of DI, which of the following
interventions should the nurse include in the plan of care? - Answer check urine specific
gravity
a nurse is caring for a pt admitted with wheezing and coughing due to an allergic
reaction to a newly prescribed medication, what medication should be administered
first? - Answer albuterol 3mL via nebulizer
, ATI Capstone Med Surg
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
