ATI CAPSTONE ADULT MEDICAL SURGICAL ASSESSMENT CORRECT QNS &
ANS COMPLETE A+ GUIDE.
• 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? (Select allthat apply)
Hepatitis A vaccine
Hepatitis B vaccine
Pneumococcal vaccine
Hepatitis C vaccine
Helicobacter pylori vaccine
Adult vaccines currently available to prevent contracting communicable diseases include those
for hepatitis A & B influenza and pneumonia. No vaccine is currently available for hep C/H.
pylori = A, B, C
• A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the
following dietary modifications should the nurse include?
Provide a snack at bedtime
Choose decaffeinated coffee
Restrict intake of fried foods
Avoid drinking liquids with meals
The nurse should instruct the client to avoid fried foods, spicy foods, and acid-producing foods,
such as coffee and chocolate. Spicy foods, such as chili pepper, red pepper, and black pepper can
cause mucosaldamage. The nurse should instruct the client to avoid decaffeinated and
caffeinated beverages and snacks at bedtime, which can stimulate gastric acid secretion. A
client with dumping syndrome, rather than peptic ulcer should avoid liquids with meals = C
• A nurse is caring for a client who is postoperative immediately following a
pheochromocytomaremoval. Which of the following actions is the nurse’s priority?
Increase hydration
Monitor blood pressure
Measure urine output
Provide a calm environment
The greatest risk to this client is injury from hypertension due to the release of catecholamines
duringsurgery or hypotension from the sudden loss of catecholamines after the tumor has been
removed.
Therefore, the priority intervention the nurse should take is to monitor the client's blood
pressure = B
,• A nurse is caring for a client who is using a ventilator when the low-pressure
ventilator alarmsounds. Which of the following actions should the nurse take?
Suction secretions from the endotracheal tubeCheck
the ventilator tubing connections Administer
intravenous sedation and analgesia
Reassure the client and instruct them not to bite on the tube
A low-pressure alarm indicates a loss of volume due to a disconnection, cuff link or tube
displacement
=B
• A nurse is assessing a client who is receiving a blood transfusion. Which of the
following findingsindicates the client might be experiencing a hemolytic transfusion
reaction?
Hypertension
Report of urticaria
Distended neck veins
Report of chest pain
Chest pain is a manifestation of a hemolytic transfusion reaction. Other manifestations
includeheadache, low back pain, and hypotension = D
• A nurse is assessing a client who has right lower lobe pneumonia. Which of the
following findingsshould the nurse expect?
Dull percussion sounds
Increased anteroposterior chest
diameter
Distended neck veins
Pitting edema
The consolidation that occurs with pneumonia will result in dull chest percussion over the
involved lobes
=A
• A nurse is providing teaching to a newly licensed nurse about caring for a client who is
receiving asealed radioactive implant. Which of the following information should the
nurse include in the teaching?
Place soiled linens in a lead container
Allow children who are over 10 years old
to visit
Limit visitors to 1 hr per day
Wear a lead apron during care
, The nurse should wear a lead apron at all times during care of a client who has a sealed
radioactiveimplant = D
• A nurse is caring for a client who has a cervical spinal cord injury. Which of the
following interventions should the nurse include in the plan of care to prevent
autonomic dysreflexia?
Monitor bowel movement regularity
Use a fan to promote air circulation to the
client’s room
Tuck the top bedsheet tightly around the
client’s torso
Monitor for cerebral spinal fluid leakage
Autonomic dysreflexia occurs secondary to the stimulation of the sympathetic nervous system
andinadequate compensatory response by the parasympathetic nervous system. Common
causes of autonomic dysreflexia include distended bladder, fecal impaction, cold stress, tight
clothing, and
undiagnosed injury or illness. The nurse should monitor the client's bowel movements to
reduce the riskof fecal impaction which can lead to autonomic dysreflexia = A
• A nurse is assessing a client who has tension pneumothorax following blunt chest trauma.
Which ofthe following findings should the nurse expect?
Tracheal deviation to the unaffected side
Pleural friction rub
Frothy, pink-tinged sputum
Increased breath sounds on the affected side
Tracheal deviation to the unaffected side occurs with tension pneumothorax because air fills the
pleuralspace on the affected side pushing the trachea and great vessels to the unaffected side =
A
• A nurse is providing instructions to a newly licensed nurse about NG intubation for a
client who is postoperative following a colectomy. Which of the following statements
should the nurse include?
“Tube drainage should be rust-colored.”
“Nutrition will be provided through the tube.”
“The tube decreases pressure within the stomach.”
“The tube should be irrigated with sterile water.”
The purpose of the tube for the client immediately following a colectomy is to promote rest
and healingof the gastrointestinal tract by decompressing and draining abdominal fluid = C
ANS COMPLETE A+ GUIDE.
• 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? (Select allthat apply)
Hepatitis A vaccine
Hepatitis B vaccine
Pneumococcal vaccine
Hepatitis C vaccine
Helicobacter pylori vaccine
Adult vaccines currently available to prevent contracting communicable diseases include those
for hepatitis A & B influenza and pneumonia. No vaccine is currently available for hep C/H.
pylori = A, B, C
• A nurse is providing discharge instructions to a client who has a peptic ulcer. Which of the
following dietary modifications should the nurse include?
Provide a snack at bedtime
Choose decaffeinated coffee
Restrict intake of fried foods
Avoid drinking liquids with meals
The nurse should instruct the client to avoid fried foods, spicy foods, and acid-producing foods,
such as coffee and chocolate. Spicy foods, such as chili pepper, red pepper, and black pepper can
cause mucosaldamage. The nurse should instruct the client to avoid decaffeinated and
caffeinated beverages and snacks at bedtime, which can stimulate gastric acid secretion. A
client with dumping syndrome, rather than peptic ulcer should avoid liquids with meals = C
• A nurse is caring for a client who is postoperative immediately following a
pheochromocytomaremoval. Which of the following actions is the nurse’s priority?
Increase hydration
Monitor blood pressure
Measure urine output
Provide a calm environment
The greatest risk to this client is injury from hypertension due to the release of catecholamines
duringsurgery or hypotension from the sudden loss of catecholamines after the tumor has been
removed.
Therefore, the priority intervention the nurse should take is to monitor the client's blood
pressure = B
,• A nurse is caring for a client who is using a ventilator when the low-pressure
ventilator alarmsounds. Which of the following actions should the nurse take?
Suction secretions from the endotracheal tubeCheck
the ventilator tubing connections Administer
intravenous sedation and analgesia
Reassure the client and instruct them not to bite on the tube
A low-pressure alarm indicates a loss of volume due to a disconnection, cuff link or tube
displacement
=B
• A nurse is assessing a client who is receiving a blood transfusion. Which of the
following findingsindicates the client might be experiencing a hemolytic transfusion
reaction?
Hypertension
Report of urticaria
Distended neck veins
Report of chest pain
Chest pain is a manifestation of a hemolytic transfusion reaction. Other manifestations
includeheadache, low back pain, and hypotension = D
• A nurse is assessing a client who has right lower lobe pneumonia. Which of the
following findingsshould the nurse expect?
Dull percussion sounds
Increased anteroposterior chest
diameter
Distended neck veins
Pitting edema
The consolidation that occurs with pneumonia will result in dull chest percussion over the
involved lobes
=A
• A nurse is providing teaching to a newly licensed nurse about caring for a client who is
receiving asealed radioactive implant. Which of the following information should the
nurse include in the teaching?
Place soiled linens in a lead container
Allow children who are over 10 years old
to visit
Limit visitors to 1 hr per day
Wear a lead apron during care
, The nurse should wear a lead apron at all times during care of a client who has a sealed
radioactiveimplant = D
• A nurse is caring for a client who has a cervical spinal cord injury. Which of the
following interventions should the nurse include in the plan of care to prevent
autonomic dysreflexia?
Monitor bowel movement regularity
Use a fan to promote air circulation to the
client’s room
Tuck the top bedsheet tightly around the
client’s torso
Monitor for cerebral spinal fluid leakage
Autonomic dysreflexia occurs secondary to the stimulation of the sympathetic nervous system
andinadequate compensatory response by the parasympathetic nervous system. Common
causes of autonomic dysreflexia include distended bladder, fecal impaction, cold stress, tight
clothing, and
undiagnosed injury or illness. The nurse should monitor the client's bowel movements to
reduce the riskof fecal impaction which can lead to autonomic dysreflexia = A
• A nurse is assessing a client who has tension pneumothorax following blunt chest trauma.
Which ofthe following findings should the nurse expect?
Tracheal deviation to the unaffected side
Pleural friction rub
Frothy, pink-tinged sputum
Increased breath sounds on the affected side
Tracheal deviation to the unaffected side occurs with tension pneumothorax because air fills the
pleuralspace on the affected side pushing the trachea and great vessels to the unaffected side =
A
• A nurse is providing instructions to a newly licensed nurse about NG intubation for a
client who is postoperative following a colectomy. Which of the following statements
should the nurse include?
“Tube drainage should be rust-colored.”
“Nutrition will be provided through the tube.”
“The tube decreases pressure within the stomach.”
“The tube should be irrigated with sterile water.”
The purpose of the tube for the client immediately following a colectomy is to promote rest
and healingof the gastrointestinal tract by decompressing and draining abdominal fluid = C
