(Answered correctly) ATI Capstone Med Surg Questions &
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
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
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?
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?
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?
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?
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?
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?
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?
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?
, 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
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?
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
lower the height of the solution container
a pt is diagnosed with left homonymous hemianopsia following a stroke, what
action should the nurse take?
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?
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
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?
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?
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?
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
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
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
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
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
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
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?
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?
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?
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?
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?
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?
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?
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?
, 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
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?
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
lower the height of the solution container
a pt is diagnosed with left homonymous hemianopsia following a stroke, what
action should the nurse take?
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?
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
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?
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?
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?
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
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
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
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
