ATI Capstone Med Surg QUESTIONS AND ANSWERS 100%

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 ANS: 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 ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: 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? ANS: albuterol 3mL via nebulizer 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 ANS: 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? ANS: 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 ANS: lower the height of the solution container a pt is diagnosed with left homonymous hemianopsia following a stroke, what action should the nurse take? ANS: 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? ANS: 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 ANS: 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? ANS: 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? ANS: 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? ANS: 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 ANS: 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 ANS: 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 ANS: 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 ANS: output of burgundy colored urine a nurse is caring for a pt who has HIV, what following lab values is the nurse's priority ANS: CD4 T cell count 180 cells/mm3 (severely immunocompromised and at high risk of infection) a nurse is teaching a pt who has GERD about managing his illness, what recommendations should the nurse include in the teaching ANS: avoid eating within 3 hours of bedtime a nurse is a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension, the nurse notes that the potassium level is 3.3, the nurse should monitor for the complication of ANS: cardiac dysrhythmias a nurse is caring for a pt with who has hepatitis A, the pt asks the nurse how he might have contracted virus, which of the following a question the nurse should ask the client? ANS: have you been to a third world country in the past a nurse is preparing a pt for a radiation treatment who is postop following a mastectomy, the nurse should inform the pt to expect what adverse effect from the treatment? ANS: fatigue a nurse is in a burn tx center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy, the client's spouse asks the nurse what the procedure entails, which of the following statements made by the nurse is appropriate ANS: large incisions will be made in the eschar to improve circulation a nurse is assessing a pt who has a herniated lumbar disc, what finding would the nurse expect ANS: the pt reports tingling and burning sensation in one foot a nurse is assessing a pt who has a history of migraine headaches with aura and reports feeling a "migraine coming on", the nurse should expect the pt to report what manifestation ANS: visual disturbance a nurse is teaching a pt who has a new diagnosis of MS about visual changes she might experience as the disease progresses, what would she include? ANS: double vision a nurse is teaching a pt who has asthma about using a peak flow meter, when a yellow zone meter reading appears, the nurse should instruct the pt to take which of the following actions ANS: take prescribed relief meds a nurse is assessing a pt who has Addison's disease, what manifestation would indicate they are experiencing the crisis ANS: hypotension (aldosterone deficit) a nurse is caring for pt who has acute gastritis and is NPO, the pt has a new prescription to resume oral intake, what item should the nurse offer the pt ANS: gelatin a nurse is providing education to a pt who is scheduled for a barium swallow, what statement indicates understanding of the teaching? ANS: i will remove my metal jewelry before coming in a nurse is caring for pt who is undergoing a liver biopsy, what instruction should the nurse provide to the pt following the procedure ANS: lie on your right side a nurse is teaching a pt who has a hiatal hernia about dietary selections to maintain lower esophageal sphincter (LES) pressure, what choice by the pt indicates understanding ANS: cheddar cheese (avoid fried, fatty, peppermint, caffeine, tomatoes, citrus fruits, and alcohol) a nurse is reviewing the lab results of a pt who has unstable angina and has been receiving heparin via continuous IV infusion for the past 5 days, what lab values should the nurse identify as an indication that the pt has developed HIT ANS: platelets 90,000 a nurse is teaching a pt who has a new diagnosis of polycystic kidney disease, what statement should the nurse include in the teaching ANS: apply dry heat to your abdomen when needed a nurse is obtaining the health history of a young adult male client, what information should indicate to the nurse that the pt is at high risk for developing testicular cancer ANS: undescended right testis a nurse is instructing a pt's caregiver on how to position the client before administering tube feedings in the home, which demonstrates understanding? ANS: i will sit him up in bed a triage nurse finds a school-age child lying in the road following a school bus crash with multiple causalities, the child has a respiratory rate of 10/min, strong distal pulses, and groans to painful stimuli, what action should the nurse take ANS: place an emergent category on the child's upper body and yell for help a nurse is caring for a client who has renal failure, what ABG result would the nurse expect ANS: ph 7.25 HCO3 20 PaCO2 35 a nurse is caring for pt who has a cerebellar tumor, what action is the nurse's priority ANS: provide assistance with ambulation a nurse is assessing a pt who has a spinal cord injury, what finding indicates the client might be experiencing neurogenic shock ANS: heart rate 52/min a nurse is caring for a pt who has renal caliculi, what prescription by the provider is the priority action for the nurse to take ANS: strictly monitor intake and output a nurse is caring for a pt who is immediately postoperative following a pheochromocytoma removal, what action is priority ANS: monitoring BP a nurse is assessing a female pt who reports severe joint pain, the nurse should identify which of the following factors places the pt at risk for gout ANS: diuretic use a nurse is caring for a pt who has a cervical spinal cord injury, what interventions should the nurse include in the plan of care to prevent autonomic dysreflexia ANS: monitor bowel movement regularity a nurse is caring for an adult client who asks about vaccinations against communicable diseases, the nurse should inform the client that which of the following vaccines are available ANS: Hep A, Hep B, Pneumococcal a nurse is providing discharge instructions to a pt following a cataract surgery, the nurse should advise the pt that he can perform what activities ANS: cooking light house work (avoid bending at the waist, or anything that can increase IOP) a nurse is teaching a pt who has angina pectoris about nitroglycerin sublingual tablets, what statements should indicate to the nurse that the pt understands the teaching ANS: i will keep the tablets in the original container a nurse is discussing risk factors for hep A with a newly licensed nurse, what client would the nurse identify as an increased risk for hep A ANS: a client who has recently done missionary work in a developing country a nurse is providing discharge teaching to a pt who had a colposcopy with cervical biopsy, what instruction should the nurse provide ANS: avoid the use of aspirin for cramping discomfort a nurse is caring for a pt who has a history of tonic clonic seizures, what precuation should the nurse take? ANS: keep a suction apparatus at the bedside, keep the bed in the lowest position, keep oxygen equipment at the bedside a nurse is caring for a pt who is postop and reports frequent leakage of small amounts of urine, the nurse notes that the client's bladder is palpable upon examination, the nurse should identify these findings as what form of incontinence ANS: overflow a nurse is assessing a pt who has a tension pneumothorax following blunt chest trauma, what should the nurse expect ANS: tracheal deviation to the unaffected side a nurse is providing instructions to a newly licensed nurse about NG intubation for a pt who is postop following a colectomy, what statement should the nurse include ANS: the tube decreases pressure within the stomach a nurse is caring for a client who had surgery 2 days ago and reports incisional pain, which of the following actions should the nurse take first? ANS: ask the pt to describe the pain and rate on a scale of 0-10 a nurse in a provider's office is caring for a client who has several moist, red, itchy skin lesions. to confirm that these lesions are fungal in origin, which of the following diagnostic tests should the nurse anticipate that the provider will prescribe ANS: potassium hydroxide (KOH) test a nurse is assessing a pt who is postop following an abdominal aortic aneurysm resection, what finding should the nurse report to the provider? ANS: decreased urine output a nurse is assessing a pt who has DKA, what finding would the nurse expect? ANS: fruity breath a nurse is assessing a pt who is postop following a kidney transplant, what finding indicates the client is experiencing a transplant rejection ANS: hypertension a nurse is assessing a pt who has GB syndrome, what should the nurse report to the provider immediately ANS: decreasing voice volume a nurse is reviewing lab reports for a pt who is taking NSAIs for RA, what results should the nurse recognize as a possible adverse effects of NSAID therapy ANS: positive fecal occult blood test a nurse is teaching strategies to prevent carpal tunnel syndrome to a group of office workers, what instructions should the nurse include ANS: use a wrist rest when working at a computer station stretch your fingers and wrists periodically while working take breaks from the repetitive activity a nurse is providing education regarding the prevention of UTIs to a client who has a history of cystitis, what statements by the client indicates that the teaching has been effective ANS: i will empty my bladder every 2-3 hours throughout the day a nurse is providing discharge teaching to a pt who is postop following a total hip arthroplasty, what statement by the pt indicates an understanding of the teaching ANS: i'll use my reaching device to help me pick up objects i drop on the floor a nurse is assessing a pt following a hypophysectomy, what finding indicates the client may be developing DI ANS: low urine specific gravity a nurse is caring for a pt who has a history of peripheral vascular disease, what should alert the nurse to an increased risk of DVT? ANS: dehydration, combination oral contraceptives, immobility, hypercalcemia a nurse is caring for a pt who has a permanent pacemaker with a ventricular demand setting of 70, which of the following findings should alert the nurse to a pacemaker malfunction ANS: apical pulse rate of 64/min a nurse is providing teaching to a pt who has a new onset of genital herpes, what statement should the nurse include in the teaching ANS: stress can activate an outbreak a nurse is caring for pt who is postop following a total laryngectomy with radical neck dissection the nurse notes that the client is restless with a respiratory rate of 26/min and audible gurglin, what is a priority action by the nurse ANS: suction the client's tracheostomy a nurse is assessing a pt who has right lower lobe pneumonia, what finding should the nurse expect? ANS: dull percussion sounds a nurse is caring for a pt who is using a ventilator when the low-pressure ventilator alarm sounds, what actions should the nurse take? ANS: check the ventilator tubing connectiosn a nurse is reviewing lab values for a client who has Cushing's disease, what values should the nurse expect ANS: sodium 150 a nurse is caring for a pt who is postop following a below-the-knee amputation, what interventions should the nurse include ANS: teach the pt to perform hip extension exercises a nurse is providing teaching to a pt who had a bone marrow biopsy taken from her iliac crest, what information should the nurse include in the teaching ANS: apply ice to the incision site a nurse is providing discharge instructions to a pt who has GERD, what statements by the pt demonstrates an understanding of the teaching? ANS: i will limit activities that require bending at the waist a nurse is caring for a pt who is hyperventilating and whose ABG results are pH 7.5, PaCO2 29, HCO3 25, based on this information the nurse should recognize that the client has what imbalance ANS: respiratory alkalosis a nurse is assessing a pt who has a new diagnosis of acute glomerulonephritis, what finding should the nurse expect ANS: brown colored urine a nurse is caring for a pt who has acute pancreatitis, what intervention should the nurse include in the client's plan of care ANS: monitor BG levels maintain NPO status until pain free manage acute pain a nurse is caring for a pt who has mild dehydration, the pt has a peripheral IV and is prescribed 0.9% sodium chloride 1,000mL with 40 mEq potassium chloride to infuse in 1 hour, what action should the nurse take first ANS: verify the prescription with the provider (risk for fluid overload and dysrhythmia from rapid potassium IV infusion) a nurse is teaching a group of APs about caring for clients with Alzheimer's disease, what info should the nurse include ANS: provide supervision to prevent a pt from becoming injured or lost a nurse is providing teaching to a pt who has acute leukemia and received chemo 5 days ago, what instruction should the nurse include in the teaching ANS: use an electric shaver avoid crowds monitor for bruising a nurse is caring for a pt who is at high risk for iron deficiency anemia, what foods should the nurse instruct the client to increase in her diet ANS: raisins a nurse is planning care for a pt who has Meniere's disease and is experiencing episodes of vertigo, what intervention should the nurse include in the plan ANS: provide a low-sodium diet (reduces fluid retention, reducing manifestations of the disease) a nurse is providing discharge instructions to a pt who has a new AV fistula to the right forearm for hemodialysis, what statement should the nurse include ANS: keep the right arm elevated above the level of your heart (prevents edema) a nurse is providing discharge teaching to a pt who has multiple sclerosis, what instruction should the nurse include in the teaching ANS: it is important to develop a daily schedule that reduces fatigue and conserves energy a nurse is providing discharge teaching to a pt who has heart failure and a prescription for furosemide 20 mg PO two times a day, what instruction should the nurse include in the teaching ANS: increase the intake of high potassium foods a nurse is providing discharge instructions to a pt who is to perform dressing changes to an incision at home, what statements by the pt indicates an understanding of the teaching ANS: "I should wash my hands before both removing and applying the dressing" a home health nurse is caring for a pt who has COPD and is on home oxygen at 2L/min via nasal cannula, the pt tells the nurse that she is experiencing difficulty breathing, what action should the nurse take first ANS: observe the pt's respiratory effort a nurse is caring for a pt who has right sided pneumothorax, following chest tube insertion what finding indicates that the chest drainage system is functioning correctly ANS: gentle bubbling in the suction chamber a nurse is providing discharge teaching to a pt who has SLE, which of the following instructions should the nurse include ANS: wear long-sleeved clothing when outdoors a nurse is teaching a pt about weight loss promotion following a laparoscopic adjustable gastric banding procedure, what statement by the pt indicates an understanding of the teaching ANS: "i will eat six small meals throughout the day after this procedure" a nurse is admitting a pt who has suspected appendicitis, what finding should the nurse report immediately ANS: distended board-like abdomen a nurse is preparing a pt who has hyperthermia for admission to a facility, which of the following room assignments should the nurse make for this client ANS: private room near the end of the hall a nurse is providing teaching to a pt who reports a possible exposure to HIV, what finding would the nurse say is an early manifestation of the infection ANS: fatigue a nurse is providing teaching a client who is scheduled for EEG, what statement by the pt indicates an understanding of the teaching ANS: i will be exposed to flashes of light during the procedure a nurse is providing dietary teaching to a pt who has chronic cholecystitis, what diet should the nurse recommend ANS: low-fat diet a nurse is providing discharge teaching to a pt who is postop following a mitral valve replacement, what instruction should the nurse include in the teaching ANS: obtain an antibiotic prescription before a dental procedure (r/f endocarditis) a nurse is providing teaching to a newly licensed nurse about caring for a pt who is receiving a sealed radioactive implant, what information should the nurse include in the teaching ANS: wear a lead apron during care a nurse in a rural community center is providing education to clients about first aid interventions for snake bites, what should the nurse include ANS: immobilize the affected extremity with a splint a nurse is providing teaching to a pt who is scheduled for exercise electrocardiography, what statements by the pt indicate understanding ANS: i should avoid caffeinated beverages on the day of the test a nurse is caring for a pt who has a new diagnosis of TB, what precaution should the nurse initiate to prevent transmission of the disease ANS: airborne precaution a nurse is providing teaching to a pt who is scheduled for electromyography (EMG), the nurse should include what info in the teaching ANS: you should expect insertion of small needle electrodes into the muscle a nurse is reviewing the med record of a pt who has unstable angina, what finding shoul dthe nurse report to the provider ANS: breath sounds (crackles) a nurse is providing teaching to a pt who is newly diagnosed with nephrotic syndrome, what statement should indicate to the nurse that the pt understands the teaching ANS: i can expect swelling in my hands and on my face (d/t loss of protein) a nurse is assessing a pt who has a heart rate of 40/min, the pt is diaphoretic and has chest pain, what medication should the nurse plan to administer ANS: atropine a nurse is caringfor a pt who is scheduled to undergo bone marrow harvesting, the nurse should instruct the pt that the harvesting will occur in which of the following situations ANS: in the OR under general anesthesia a nurse is caring for a pt who has a closed head injury, what following finding indicates the need for immediate intervention ANS: respiratory rate 24/min with increased depth a nurse is providing discharge instructions to a pt who has a peptic ulcer, what dietary modification should the nurse include ANS: restrict intake of fried foods a nurse is caring for a pt who has SIADH, and is receiving 3% sodium chloride via continuous IV, what lab findings should the nurse identify as an indication the SIADH is resolving ANS: urine specific gravity 1.020 a nurse is providing teaching to a pt who has contact dermatitis on her face and neck, what statement by the pt indicates an understanding of the teaching ANS: i should apply cool, moist compresses to the rash a nurse is providing discharge instructions for a pt who is starting to take carbidopa/levodopa to treat PD, what instruction should the nurse include in the teaching ANS: this med can cause your urine to turn a dark color (also saliva and sweat) a nurse in an ICU is caring for a client who has a PE, what action should the nurse take first ANS: initiate O2 therapy a nurse is reviewing the r/f of osteoporosis with a group of pts, the nurse should instruct which of the following increases the risk of developing osteoporosis ANS: early menopause a nurse is teaching a pt about using a CPAP, to treat obstructive sleep apnea, what should the nurse include in teaching ANS: it delivers a preset amount of airway pressure throughout the breathing cycle a nurse is assessing a pt who has a sodium level of 122, what findings should the nurse expect ANS: decreased deep-tendon reflexes a nurse is assessing a pt who has meningitis, the nurse should identify which of the following findings as a positive Kernig's sign ANS: after hip flexion, the pt is unstable to extend his leg completely without pain a nurse in an emergency department is caring for a pt who has sustained multiple injuries, the nurse observes the pt's thorax moving inward during inspiration and outward during expiration, the nurse should suspect which of the following injuries ANS: flail chest a nurse is teaching a pt who has osteoarthritis and is scheduled for a left hip arthroplasty, the nurse should explain that which of the following is the purpose of the procedure ANS: improve joint range of motion a nurse is caring for apt who is postop following a bronchoscopy, what actions are the nurses priority ANS: determine the pts gag reflex a nurse is caring for a client who had an intravenous pyelogram (IVP) which of the following interventions should the nurse implement ANS: encourage an increase in fluid intake a nurse is teaching a pt about fecal occult blood testing (FOBT) for the screening of colorectal cancer, what statement should the nurse include in the teaching ANS: you should avoid eating red meat prior to testing a nurse is teaching a client who has hypertension about dietary modifications to help control BP, what food choices should the nurse recommend ANS: 3 oz of chicken breast a nurse is teaching a pt who has type 1 DM about hypoglycemia, what statement by the pt indicates an understanding of the teaching ANS: i can drink 4 ounces of soda if my blood sugar is low a nurse is planning care for a client who has acute post-streptococcal glomerulonephritis, what interventions should the nurse include in the pt's plan of care ANS: administer diuretics to the client (sodium and fluid restrictions help reduce edem