ATI Capstone
Adult Medical
Surgical
Assessment 2
• A nurse is teaching a group of assistive personnel (AP) about caring for Patientswho have
Alzheimer's disease. Which of the following information should the nurse include in the
teaching?
Explain procedures in full detail to Patients before
initiating careLimit a Patients’s activities to minimize
emotional outbursts
Speak clearly and loudly to a Patients who is unable to form words or
sentencesProvide supervision to prevent a Patients from becoming
injured or lost
A Patients who has Alzheimer's disease can wander and become lost. The AP should initiate
interventionsto keep the Patients safe, such as redirection, frequent monitoring, and
reorientation. The AP should encourage a Patients who has Alzheimer's disease to
participate in activities for as long as possible because socializing with others can provide the
Patients with comfort = D
• A nurse is developing a plan of care for a Patients who will be placed in halo traction
following surgicalrepair of the cervical spine. Which of the following interventions should
the nurse include in the plan?
Inspect the pin site every 4 hr
Monitor the Patients’s skin under the halo vest
Ensure two personnel hold the halo device when repositioning the
Patients Apply powder frequently to the Patients’s skin under the
vest to decrease itching
The nurse should monitor the Patients’s skin that is under the halo vest for excessive
sweating, redness, orblistering which can lead to skin breakdown and infection. To ensure
the vest is not causing pressure, the nurse should be able to insert one finger between the
jacket and the skin with ease = B
,• A nurse is providing discharge teaching for a Patients who has COPD about nutrition.
Which of thefollowing instructions should the nurse include?
Eat three large
meals daily
Consume high-
calorie foods
Limit caffeinated drinks to
two per dayDrink fluids
during meal time
The nurse should instruct the Patients to consume high-calorie, high-protein foods to provide
energy andprevent weight loss = B
• A nurse is caring for a Patients who has anew diagnosis of tuberculosis. Which of
the followingprecautions should the nurse initiate to prevent transmission of the
disease?
Contact
precautions
Airborne
precautions
Droplet
precautions
Protective
environment
Tuberculosis is spread through small droplets, measuring less than 5 microns, which can
remain airborne for extended periods. The nurse should place a Patients who has TB under
airborne precautions to prevent the spread of microbes. For airborne precautions, the
Patients should be placed in a private, negative pressure room with 6 – 12 air exchanges per
hour with HEPA filtration. The nurse should wearan N95 respirator while providing care to
the Patients. Nurse should also teach Patients to cough and expectorate sputum into tissues,
which are disposed of in a waterproof sack = B
• A nurse is preparing a Patients for a colonoscopy. Which of the following medications
should the nurseanticipate the provider to prescribe as an anesthetic for the
procedure?Propofol Pancuronium PromethazinePentoxifylline
The nurse should identify that propofol is a short-acting anesthetic medication that can be
used tocause moderate sedation for procedures, such as a colonoscopy = A
, • A nurse is teaching a group of Patientsabout the risk factors for osteoporosis. Which of
the followingshould the nurse include as a risk factor for osteoporosis?Early menopause
History of falls
African
American
raceObesity
A Patients who goes into early menopause, form natural or surgical causes, is at a greater
risk for developing osteoporosis due to the rapid drop in estrogen levels. Decreased estrogen
leads to anincrease in bone decay & decrease in the production of osteoclasts that produce
new bone.
Osteoporosis is the most common metabolic bone disorder that results in low bone
density. It occurs when the rate of bone resorption exceeds the rate of bone formation,
resulting in fragile bone tissueand subsequent fractures = A
• A nurse is caring for a Patients who has a peripherally inserted central catheter (PICC).
For which ofthe following findings should the nurse notify the provider?
The dressing was changed 7 days ago
The circumference of the Patients’s upper arm has
increased by 10%The catheter has not been used in 8 hr
The catheter has been flushed with 10 mL of sterile saline after medication use
Circumference of the upper arm above the insertion site of the PICC should be measured at
the time ofinsertion & then again during assessments. An increase in the circumference could
indicate deep vein thrombosis, which could be life threatening. The nurse should contact the
provider immediately aboutthis finding = B
• A nurse is reviewing the medical record of a Patients who has unstable angina. Which of
the followingfindings should the nurse report to the provider?
Exhibit 1 – Graphic record: BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min,
Resp rate 26/min, urine output
90 mL/h hrExhibit 2 – Nurse’s notes: Skin is cool & moist
with pallor need.
Bilateral breath sounds with crackles heard at bases of
lungs.Pedal pulses are present at 1+ bilateral.
Exhibit 3 – Diagnostic results: Creatine kinase 100 units/L
C-reactive protein
0.8 mg/dL
Myoglobin 88
mcg/LBreath
sounds
Temperature
Adult Medical
Surgical
Assessment 2
• A nurse is teaching a group of assistive personnel (AP) about caring for Patientswho have
Alzheimer's disease. Which of the following information should the nurse include in the
teaching?
Explain procedures in full detail to Patients before
initiating careLimit a Patients’s activities to minimize
emotional outbursts
Speak clearly and loudly to a Patients who is unable to form words or
sentencesProvide supervision to prevent a Patients from becoming
injured or lost
A Patients who has Alzheimer's disease can wander and become lost. The AP should initiate
interventionsto keep the Patients safe, such as redirection, frequent monitoring, and
reorientation. The AP should encourage a Patients who has Alzheimer's disease to
participate in activities for as long as possible because socializing with others can provide the
Patients with comfort = D
• A nurse is developing a plan of care for a Patients who will be placed in halo traction
following surgicalrepair of the cervical spine. Which of the following interventions should
the nurse include in the plan?
Inspect the pin site every 4 hr
Monitor the Patients’s skin under the halo vest
Ensure two personnel hold the halo device when repositioning the
Patients Apply powder frequently to the Patients’s skin under the
vest to decrease itching
The nurse should monitor the Patients’s skin that is under the halo vest for excessive
sweating, redness, orblistering which can lead to skin breakdown and infection. To ensure
the vest is not causing pressure, the nurse should be able to insert one finger between the
jacket and the skin with ease = B
,• A nurse is providing discharge teaching for a Patients who has COPD about nutrition.
Which of thefollowing instructions should the nurse include?
Eat three large
meals daily
Consume high-
calorie foods
Limit caffeinated drinks to
two per dayDrink fluids
during meal time
The nurse should instruct the Patients to consume high-calorie, high-protein foods to provide
energy andprevent weight loss = B
• A nurse is caring for a Patients who has anew diagnosis of tuberculosis. Which of
the followingprecautions should the nurse initiate to prevent transmission of the
disease?
Contact
precautions
Airborne
precautions
Droplet
precautions
Protective
environment
Tuberculosis is spread through small droplets, measuring less than 5 microns, which can
remain airborne for extended periods. The nurse should place a Patients who has TB under
airborne precautions to prevent the spread of microbes. For airborne precautions, the
Patients should be placed in a private, negative pressure room with 6 – 12 air exchanges per
hour with HEPA filtration. The nurse should wearan N95 respirator while providing care to
the Patients. Nurse should also teach Patients to cough and expectorate sputum into tissues,
which are disposed of in a waterproof sack = B
• A nurse is preparing a Patients for a colonoscopy. Which of the following medications
should the nurseanticipate the provider to prescribe as an anesthetic for the
procedure?Propofol Pancuronium PromethazinePentoxifylline
The nurse should identify that propofol is a short-acting anesthetic medication that can be
used tocause moderate sedation for procedures, such as a colonoscopy = A
, • A nurse is teaching a group of Patientsabout the risk factors for osteoporosis. Which of
the followingshould the nurse include as a risk factor for osteoporosis?Early menopause
History of falls
African
American
raceObesity
A Patients who goes into early menopause, form natural or surgical causes, is at a greater
risk for developing osteoporosis due to the rapid drop in estrogen levels. Decreased estrogen
leads to anincrease in bone decay & decrease in the production of osteoclasts that produce
new bone.
Osteoporosis is the most common metabolic bone disorder that results in low bone
density. It occurs when the rate of bone resorption exceeds the rate of bone formation,
resulting in fragile bone tissueand subsequent fractures = A
• A nurse is caring for a Patients who has a peripherally inserted central catheter (PICC).
For which ofthe following findings should the nurse notify the provider?
The dressing was changed 7 days ago
The circumference of the Patients’s upper arm has
increased by 10%The catheter has not been used in 8 hr
The catheter has been flushed with 10 mL of sterile saline after medication use
Circumference of the upper arm above the insertion site of the PICC should be measured at
the time ofinsertion & then again during assessments. An increase in the circumference could
indicate deep vein thrombosis, which could be life threatening. The nurse should contact the
provider immediately aboutthis finding = B
• A nurse is reviewing the medical record of a Patients who has unstable angina. Which of
the followingfindings should the nurse report to the provider?
Exhibit 1 – Graphic record: BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min,
Resp rate 26/min, urine output
90 mL/h hrExhibit 2 – Nurse’s notes: Skin is cool & moist
with pallor need.
Bilateral breath sounds with crackles heard at bases of
lungs.Pedal pulses are present at 1+ bilateral.
Exhibit 3 – Diagnostic results: Creatine kinase 100 units/L
C-reactive protein
0.8 mg/dL
Myoglobin 88
mcg/LBreath
sounds
Temperature
