Science Medicine Nursing
Capstone ATI NCLEX Medical Surgical
Assessment 1
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A nurse is teaching a client how D .) "Shake the inhaler vigorously prior to use"
to administer a medication using Thoroughly shake the inhaler to disperse the medication because
an inhaler with a spacer. Which the medication in the inhaler can separate easily
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"
A nurse is planning care for a A.) Provide the client with a means of communication
client who is receiving
mechanical ventilation. Which of Use electronic tablet computer, programmable speech
the following actions should the generating device, alphabet board, pencil and paper, etc
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
,A nurse is caring for a client who C Urine specific gravity 1.020
is receiving IV fluid replacement Within the expected range of 1.005-1.030
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%
A nurse is monitoring the C Platelets 80,000
laboratory findings for a client platelet range is 150,000-400,000
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
A nurse is admitting a client who D Assist the client with quad coughing
has a cervical spinal cord injury The greatest risk to a client who has a cervical spinal cord injury
following a motor vehicle crash. is an obstructed airway; the priority is to ensure the client can
Which of the following clear their airway. Apply abdominal pressure as the client coughs
interventions is the nurse's (quad coughing)
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
A nurse is caring for a client who C Dyspnea
is receiving a blood transfusion. Dyspnea is an indication of possible transfusion associated
Which of the following findings circulatory overload, leading to hypertension, bounding pulses,
indicates that the client is and confusion. Dyspnea can also indicate transfusion related
experiencing transfusion- acute lung injury to an anaphylactic response, which also causes
associated circulatory overload wheezing, chest tightness, cyanosis, and low BP
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia
, A nurse is assessing a client who C Altered taste sensations
has lung cancer and is Altered taste is a result of the release of metabolites by dead
undergoing radiation therapy to cells
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
A nurse is preparing to A, D, E
administer a unit of packed A, complete assessment prior to transfusion
RBCs to a client who has
anemia. Which of the following D, verify identification, blood compatibility, and expiration of
actions should the nurse plan to product with second nurse
take (select all that apply)
E, the nurse should use a large bore needle to transfuse the
A. Obtain pre-transfusion PRBCs to reduce the risk of cell hemolysis and obstruction of
temperature flow
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
A nurse is reviewing the D 26 mg/dL
laboratory findings for a client
who is dehydrated. Which of the Normal range is 10-20, and elevated levels indicates renal
following BUN levels should the disease, dehydration, shock, excessive protein in the diet, sepsis,
nurse expect glucocorticoid use, GI bleeding, or other conditions in which
blood is reabsorbed from injured tissues
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL
Capstone ATI NCLEX Medical Surgical
Assessment 1
Save
Students also studied
Flashcard sets Study guides
ATI Capstone Adult Medical Surgica... CMS peds Monday retake pain management
50 terms Teacher 59 terms 14 terms
Kalopes84 Preview richchenel Preview Maevesmom
A nurse is teaching a client how D .) "Shake the inhaler vigorously prior to use"
to administer a medication using Thoroughly shake the inhaler to disperse the medication because
an inhaler with a spacer. Which the medication in the inhaler can separate easily
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"
A nurse is planning care for a A.) Provide the client with a means of communication
client who is receiving
mechanical ventilation. Which of Use electronic tablet computer, programmable speech
the following actions should the generating device, alphabet board, pencil and paper, etc
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
,A nurse is caring for a client who C Urine specific gravity 1.020
is receiving IV fluid replacement Within the expected range of 1.005-1.030
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%
A nurse is monitoring the C Platelets 80,000
laboratory findings for a client platelet range is 150,000-400,000
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
A nurse is admitting a client who D Assist the client with quad coughing
has a cervical spinal cord injury The greatest risk to a client who has a cervical spinal cord injury
following a motor vehicle crash. is an obstructed airway; the priority is to ensure the client can
Which of the following clear their airway. Apply abdominal pressure as the client coughs
interventions is the nurse's (quad coughing)
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
A nurse is caring for a client who C Dyspnea
is receiving a blood transfusion. Dyspnea is an indication of possible transfusion associated
Which of the following findings circulatory overload, leading to hypertension, bounding pulses,
indicates that the client is and confusion. Dyspnea can also indicate transfusion related
experiencing transfusion- acute lung injury to an anaphylactic response, which also causes
associated circulatory overload wheezing, chest tightness, cyanosis, and low BP
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia
, A nurse is assessing a client who C Altered taste sensations
has lung cancer and is Altered taste is a result of the release of metabolites by dead
undergoing radiation therapy to cells
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
A nurse is preparing to A, D, E
administer a unit of packed A, complete assessment prior to transfusion
RBCs to a client who has
anemia. Which of the following D, verify identification, blood compatibility, and expiration of
actions should the nurse plan to product with second nurse
take (select all that apply)
E, the nurse should use a large bore needle to transfuse the
A. Obtain pre-transfusion PRBCs to reduce the risk of cell hemolysis and obstruction of
temperature flow
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
A nurse is reviewing the D 26 mg/dL
laboratory findings for a client
who is dehydrated. Which of the Normal range is 10-20, and elevated levels indicates renal
following BUN levels should the disease, dehydration, shock, excessive protein in the diet, sepsis,
nurse expect glucocorticoid use, GI bleeding, or other conditions in which
blood is reabsorbed from injured tissues
A. 3.6 mg/dl
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL
