Ati capstone medical surgical assessment exam 3

ATI Capstone Medical Surgical assessment NCLEX Exam with 60Ǫ
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uestions and Verified Rationalized Answers e e e e




100% Graded A+ (2024/2025) e e e




1. A nurse is planning care for a client who is receiving mechanical ventilation. Which of thefol
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lowing actions should the nurse include in the plan
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A. Provide the client with a means of communication
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B. Maintain the head of the client's bed in a flat position
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C. Suction the client's endotracheal tube every 4 hr
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D. Perform oral hygiene for the client every 8 hr: A
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Use electronic tablet computer, programmable speech generating device, alphabet board, penc
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and paper, etc
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B, keep head of bed higher than 30 degrees to prevent aspiration and ventilator associatedpneum
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onia.Turn the client q 2hr to prevent complications related to immobility
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C, assess the need to suction q 2-
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4 hr, but not perform routine suctioning. Base the need forsuctioning on assessments, not a sch
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dule. Unnecessary suctioning can cause bronco spasms and injury tracheal mucosa
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D, oral hygiene should be performed q 2 hr to decrease the risk of ventilator associated
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,pneumonia
2. A nurse is caring for a client who is receiving IV fluid replacement therapy fordehydrati
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on. Which of the following laboratory results indicates effective- ness of the treatment
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A. Sodium 165 mEq/L e e




B. Potassium 5.2 mEq/L e e




C. Urine specific gravity 1.020
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D. Hct 62%: C e e




Within the expected range of 1.005-1.030
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A, sodium range is 136-
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145 B,potassium range is 3.5-
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5 D, Hct range is 37%-52%
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,3. A nurse is monitoring the laboratory findings for a client who is postoper-
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e ative following a total hip arthroplasty 6 hr ago.Which of the following values indicates that
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the client has an increased risk for bleeding
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A. PT 11.5 seconds e e




B. aPTT 35 seconds e e




C. Platelets 80,000 e




D. RBC 4.0 million: C e e e




platelet range is 150,000-400,000 e e e




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A, PT range is 11-12.5
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B, aPTT range is 30-40 seconds
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D, RBC range is 4.2-
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6.1 million. A low RBCcan indicate that bleeding has occurred, but it does not indicate that the c
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ent is at risk for bleeding
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4. A nurse is admitting a client who has a cervical spinal cord injury following a motor veh
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icle crash.Which of the following interventions is the nurse's priority while caring for this cl
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ient

A. Change the client's position every 2 hours e e e e e e




B. Pad pressure points at the edges of the client's cervical collar
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C. Palpate the client's abdomen for bladder distention e e e e e e




D. Assist the client with quad coughing: D e e e e e e



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, The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the
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