ATI CAPSTONE ADULT MEDICAL SURGICAL
ASSESSMENT 2 NEWEST COMPLETE 50 ACTUAL
QUESTIONS AND CORRECT DETAILED ANSWERS
(CORRECT VERIFIED ANSWERS) LATEST UPDATED
VERSION |ALREADY GRADED A+
A nurse is teaching a client how to administer a medication using an inhaler with a
spacer. Which of the following instructions should the nurse include
A. "Wait at least 5 minutes between puffs from the same inhaler"
B. "Breathe in rapidly when inhaling the medication"
C. "Clean the plastic inhaler cap weekly with cold water"
D. "Shake the inhaler vigorously prior to use" - ANSWER: D .) "Shake the inhaler
vigorously prior to use"
Thoroughly shake the inhaler to disperse the medication because the medication in
the inhaler can separate easily
A nurse is planning care for a client who is receiving mechanical ventilation. Which of
the following actions should the nurse include in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - ANSWER: A.) Provide the client
with a means of communication
Use electronic tablet computer, programmable speech generating device, alphabet
board, pencil and paper, etc
A nurse is caring for a client who is receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effectiveness of the
treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - ANSWER: C Urine specific gravity 1.020
Within the expected range of 1.005-1.030
A nurse is monitoring the laboratory findings for a client who is postoperative
following a total hip arthroplasty 6 hr ago. Which of the following values indicates
that the client has an increased risk for bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
,C. Platelets 80,000
D. RBC 4.0 million - ANSWER: C Platelets 80,000
platelet range is 150,000-400,000
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 - ANSWER: 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 caring for a client who is receiving a blood transfusion. Which of the
following findings indicates that the client is experiencing transfusion-associated
circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - ANSWER: C Dyspnea
Dyspnea is an indication of possible transfusion associated circulatory overload,
leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate
transfusion related acute lung injury to an anaphylactic response, which also causes
wheezing, chest tightness, cyanosis, and low BP
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 - ANSWER: C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia.
Which of the following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access - ANSWER: A, D, E
, A, complete assessment prior to transfusion
D, verify identification, blood compatibility, and expiration of product with second
nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk
of cell hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of
the following BUN levels should the nurse expect
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL - ANSWER: D 26 mg/dL
Normal range is 10-20, and elevated levels indicates renal disease, dehydration,
shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other
conditions in which blood is reabsorbed from injured tissues
A nurse is reviewing ECG strips for several clients. Which of the following images
should the nurse identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate
somewhere other than the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min - ANSWER: A.) multiple irregular and
variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from the
operating room. Which of the following items is the priority for the nurse to have
available in the client's room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula - ANSWER: A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or
decannulation to maintain an airway until a new trach tube can be placed. For the
ASSESSMENT 2 NEWEST COMPLETE 50 ACTUAL
QUESTIONS AND CORRECT DETAILED ANSWERS
(CORRECT VERIFIED ANSWERS) LATEST UPDATED
VERSION |ALREADY GRADED A+
A nurse is teaching a client how to administer a medication using an inhaler with a
spacer. Which of the following instructions should the nurse include
A. "Wait at least 5 minutes between puffs from the same inhaler"
B. "Breathe in rapidly when inhaling the medication"
C. "Clean the plastic inhaler cap weekly with cold water"
D. "Shake the inhaler vigorously prior to use" - ANSWER: D .) "Shake the inhaler
vigorously prior to use"
Thoroughly shake the inhaler to disperse the medication because the medication in
the inhaler can separate easily
A nurse is planning care for a client who is receiving mechanical ventilation. Which of
the following actions should the nurse include in the plan
A. Provide the client with a means of communication
B. Maintain the head of the client's bed in a flat position
C. Suction the client's endotracheal tube every 4 hr
D. Perform oral hygiene for the client every 8 hr - ANSWER: A.) Provide the client
with a means of communication
Use electronic tablet computer, programmable speech generating device, alphabet
board, pencil and paper, etc
A nurse is caring for a client who is receiving IV fluid replacement therapy for
dehydration. Which of the following laboratory results indicates effectiveness of the
treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - ANSWER: C Urine specific gravity 1.020
Within the expected range of 1.005-1.030
A nurse is monitoring the laboratory findings for a client who is postoperative
following a total hip arthroplasty 6 hr ago. Which of the following values indicates
that the client has an increased risk for bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
,C. Platelets 80,000
D. RBC 4.0 million - ANSWER: C Platelets 80,000
platelet range is 150,000-400,000
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 - ANSWER: 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 caring for a client who is receiving a blood transfusion. Which of the
following findings indicates that the client is experiencing transfusion-associated
circulatory overload
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - ANSWER: C Dyspnea
Dyspnea is an indication of possible transfusion associated circulatory overload,
leading to hypertension, bounding pulses, and confusion. Dyspnea can also indicate
transfusion related acute lung injury to an anaphylactic response, which also causes
wheezing, chest tightness, cyanosis, and low BP
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 - ANSWER: C Altered taste sensations
Altered taste is a result of the release of metabolites by dead cells
A nurse is preparing to administer a unit of packed RBCs to a client who has anemia.
Which of the following actions should the nurse plan to take (select all that apply)
A. Obtain pre-transfusion temperature
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client during the transfusion
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access - ANSWER: A, D, E
, A, complete assessment prior to transfusion
D, verify identification, blood compatibility, and expiration of product with second
nurse
E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the risk
of cell hemolysis and obstruction of flow
A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of
the following BUN levels should the nurse expect
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL - ANSWER: D 26 mg/dL
Normal range is 10-20, and elevated levels indicates renal disease, dehydration,
shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other
conditions in which blood is reabsorbed from injured tissues
A nurse is reviewing ECG strips for several clients. Which of the following images
should the nurse identify as atrial fibrillation
(cannot insert pictures, read description)
A. multiple irregular and variable waves at the baseline and irregular R to R intervals
B. a rate of 140-180/min
C. a tachycardia with no identifiable P wave and is determined to originate
somewhere other than the ventricles. Rate between 100-280/min
D. a P wave for every QRS, rate is 60-100/min - ANSWER: A.) multiple irregular and
variable waves at the baseline and irregular R to R intervals
A nurse is preparing to admit a client who has a new tracheostomy from the
operating room. Which of the following items is the priority for the nurse to have
available in the client's room upon admission
A. Obturator
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula - ANSWER: A.) Obturator
The obturator can be inserted in the stoma in the even of dislodgment or
decannulation to maintain an airway until a new trach tube can be placed. For the
