ATI Capstone Med Surg – Questions And
Answers
a nurse is reviewing the ABG results of a client who the provider
suspects has metabolic acidosis. what would the nurse expect to
see
CORRECT 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
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT ANSWER:-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
CORRECT 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?
, CORRECT 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
CORRECT 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?
CORRECT 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?
CORRECT 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
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT ANSWER:-localized erythema
Answers
a nurse is reviewing the ABG results of a client who the provider
suspects has metabolic acidosis. what would the nurse expect to
see
CORRECT 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
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT ANSWER:-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
CORRECT 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?
, CORRECT 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
CORRECT 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?
CORRECT 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?
CORRECT 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
CORRECT 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?
CORRECT 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?
CORRECT 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?
CORRECT ANSWER:-localized erythema
