Capstone ATI NCLEX Medical Surgical
Assessment 1Question And Answers
- -
- A nurse in a postanesthesia care unit is performing a postoperative
assessment on a client who is recovering from a lumbar laminectomy and
has a surgical drain. Which of the following findings should the nurse
identify as a complication of the procedure
A. Clear drainage on the surgical dressing
B. Pain level of 5 on a scale from 0 to 10
C. Reports discomfort when log rolling
D. Drainage output 30m: during the first hour - -A. Clear drainage on the
surgical dressing
Clear fluid on or around the surgical dressing following a laminectomy is
an indication of CSF leak. Place the client flat to prevent a spinal headache
and notify provider immediately
- A nurse in an emergency department is monitoring a client who reports
angina. Which of the following findings should indicate to the nurse that
the client might have experienced a myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL - -A ) Increased troponin
Troponin is a myocardial muscle protein released into the blood stream as
a result of injury to the heart muscle. Troponin levels increase within 2-3
hr following an MI
- A nurse in an endoscopy clinic is providing teaching to a client who is
to undergo a colonoscopy for colon cancer screening. Which of the
following information should the nurse provide
A. "You should have nothing to eat or drink for 3 hours prior to the
procedure"
B. "You should drink the bowel preparation slowly to prevent nausea"
C. "You will have no discomfort following the procedure"
D. "You will need someone to drive you home after your procedure" - -D.)
"You will need someone to drive you home after your procedure"
Do not drive for 12-18 hours following the procedure, because during a
colonoscopy, the pt receives moderate sedation
, - A nurse in the emergency department is caring for a client who has a
traumatic brain injury (TBI). Which of the following assessment findings
should the nurse recognize as a late manifestation of increased
intracranial pressure (ICP) (select all that apply)
A. Tachypnea
B. Increased restlessness
C. Bradycardia
D. Asymmetric pupils
E. Widened pulse pressure - --Bradycardia
-Asymmetric pupils
-Widened pulse pressure
- A nurse in the ICU is caring for a client who is reporting heart
palpitations. The nurse notes ventricular tachycardia on the ECG monitor.
Which of the following actions should the nurse take
A. Defibrillate the client
B. Prepare the client for cardioversion
C. Initiate CPR
D. Administer digoxin - -B. Prepare the client for cardioversion
cardioversion is a synchronized countershock that uses a pulse to help
convert vtach back to sinus rhythm for a client who is STABLE AND
RESPONSIVE
- A nurse is administering epinephrine IV to a client who is having an
anaphylactic reaction. Which of the following findings should the nurse
identify as a therapeutic response to the medication
A. Hypoglycemia
B. Thickened bronchial secretions
C. Regular heart rate with hypotension
D. Non itchy skin wheals - -D) Non itchy skin wheals
A pt in anaphylactic shock can experience intensely itchy skin with wheals
or hives that can merge to form large red blotches. Epi blocks the release
of histamine and decreases erythema, angioedema, and hives
- A nurse is administering parenteral nutrition to a client who has a
history of heart failure. Which of the following manifestations indicates to
the nurse that the client is experiencing fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss - -C
when the client is recumbent, the extracellular fluid enters the vascular
system and increases the blood volume filtering through the kidneys,
which increases urine production
, --
A, hypertension indicates fluid overload in a pt with heart failure
B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume overload
in a client who has heart failure
- A nurse is admitting a client who has a cervical spinal cord injury
following a motor vehicle crash. Which of the following interventions is the
nurse's priority while caring for this client
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - -D Assist the client with quad
coughing
The greatest risk to a client who has a cervical spinal cord injury is an
obstructed airway; the priority is to ensure the client can clear their
airway. Apply abdominal pressure as the client coughs (quad coughing)
- A nurse is assessing a client who has a calcium level of 12.3 mg/dL.
Which of the following findings should the nurse expect
A. lethargy
B. muscle spasms
C. positive chvostek's sign
D. shortened P-R interval - -A. lethargy
12.3 calcium indicates hypercalcemia (range is 9-10.5).
- A nurse is assessing a client who has lung cancer and is undergoing
radiation therapy to the chest. Which of the following indicates an adverse
effect of the therapy
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold - -C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
- A nurse is assisting in selecting foods for lunch with a client who has
diverticulosis. Which of the following foods should the nurse recommend
as the best source of fiber
A. 1 slice of rye bread
B. 1/2 cup cooked navy beans
C. 1/2 cup cooked asparagus
Assessment 1Question And Answers
- -
- A nurse in a postanesthesia care unit is performing a postoperative
assessment on a client who is recovering from a lumbar laminectomy and
has a surgical drain. Which of the following findings should the nurse
identify as a complication of the procedure
A. Clear drainage on the surgical dressing
B. Pain level of 5 on a scale from 0 to 10
C. Reports discomfort when log rolling
D. Drainage output 30m: during the first hour - -A. Clear drainage on the
surgical dressing
Clear fluid on or around the surgical dressing following a laminectomy is
an indication of CSF leak. Place the client flat to prevent a spinal headache
and notify provider immediately
- A nurse in an emergency department is monitoring a client who reports
angina. Which of the following findings should indicate to the nurse that
the client might have experienced a myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL - -A ) Increased troponin
Troponin is a myocardial muscle protein released into the blood stream as
a result of injury to the heart muscle. Troponin levels increase within 2-3
hr following an MI
- A nurse in an endoscopy clinic is providing teaching to a client who is
to undergo a colonoscopy for colon cancer screening. Which of the
following information should the nurse provide
A. "You should have nothing to eat or drink for 3 hours prior to the
procedure"
B. "You should drink the bowel preparation slowly to prevent nausea"
C. "You will have no discomfort following the procedure"
D. "You will need someone to drive you home after your procedure" - -D.)
"You will need someone to drive you home after your procedure"
Do not drive for 12-18 hours following the procedure, because during a
colonoscopy, the pt receives moderate sedation
, - A nurse in the emergency department is caring for a client who has a
traumatic brain injury (TBI). Which of the following assessment findings
should the nurse recognize as a late manifestation of increased
intracranial pressure (ICP) (select all that apply)
A. Tachypnea
B. Increased restlessness
C. Bradycardia
D. Asymmetric pupils
E. Widened pulse pressure - --Bradycardia
-Asymmetric pupils
-Widened pulse pressure
- A nurse in the ICU is caring for a client who is reporting heart
palpitations. The nurse notes ventricular tachycardia on the ECG monitor.
Which of the following actions should the nurse take
A. Defibrillate the client
B. Prepare the client for cardioversion
C. Initiate CPR
D. Administer digoxin - -B. Prepare the client for cardioversion
cardioversion is a synchronized countershock that uses a pulse to help
convert vtach back to sinus rhythm for a client who is STABLE AND
RESPONSIVE
- A nurse is administering epinephrine IV to a client who is having an
anaphylactic reaction. Which of the following findings should the nurse
identify as a therapeutic response to the medication
A. Hypoglycemia
B. Thickened bronchial secretions
C. Regular heart rate with hypotension
D. Non itchy skin wheals - -D) Non itchy skin wheals
A pt in anaphylactic shock can experience intensely itchy skin with wheals
or hives that can merge to form large red blotches. Epi blocks the release
of histamine and decreases erythema, angioedema, and hives
- A nurse is administering parenteral nutrition to a client who has a
history of heart failure. Which of the following manifestations indicates to
the nurse that the client is experiencing fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss - -C
when the client is recumbent, the extracellular fluid enters the vascular
system and increases the blood volume filtering through the kidneys,
which increases urine production
, --
A, hypertension indicates fluid overload in a pt with heart failure
B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume overload
in a client who has heart failure
- A nurse is admitting a client who has a cervical spinal cord injury
following a motor vehicle crash. Which of the following interventions is the
nurse's priority while caring for this client
A. Change the client's position every 2 hours
B. Pad pressure points at the edges of the client's cervical collar
C. Palpate the client's abdomen for bladder distention
D. Assist the client with quad coughing - -D Assist the client with quad
coughing
The greatest risk to a client who has a cervical spinal cord injury is an
obstructed airway; the priority is to ensure the client can clear their
airway. Apply abdominal pressure as the client coughs (quad coughing)
- A nurse is assessing a client who has a calcium level of 12.3 mg/dL.
Which of the following findings should the nurse expect
A. lethargy
B. muscle spasms
C. positive chvostek's sign
D. shortened P-R interval - -A. lethargy
12.3 calcium indicates hypercalcemia (range is 9-10.5).
- A nurse is assessing a client who has lung cancer and is undergoing
radiation therapy to the chest. Which of the following indicates an adverse
effect of the therapy
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold - -C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
- A nurse is assisting in selecting foods for lunch with a client who has
diverticulosis. Which of the following foods should the nurse recommend
as the best source of fiber
A. 1 slice of rye bread
B. 1/2 cup cooked navy beans
C. 1/2 cup cooked asparagus
