Capstone ATI NCLEX Medical Surgical Assessment 1 QUESTIONS WITH ANSWERS

Capstone ATI NCLEX Medical Surgical \| \| \| \| \|




Assessment 1 QUESTIONS WITH \| \| \| \|




ANSWERS

A nurse is teaching a client how to administer a medication
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using an inhaler with a spacer. Which of the following
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instructions should the nurse include \| \| \| \|




A. "Wait at least 5 minutes between puffs from the same inhaler"
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B. "Breathe in rapidly when inhaling the medication"
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C. "Clean the plastic inhaler cap weekly with cold water"
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D. "Shake the inhaler vigorously prior to use" - CORRECT
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ANSWERS ✔✔D .) "Shake the inhaler vigorously prior to use"
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Thoroughly shake the inhaler to disperse the medication
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because the medication in the inhaler can separate easily
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A nurse is planning care for a client who is receiving mechanical
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ventilation. Which of the following actions should the nurse
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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 - CORRECT
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ANSWERS ✔✔A.) Provide the client with a means of
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communication


Use electronic tablet computer, programmable speech generating
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device, alphabet board, pencil and paper, etc
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A nurse is caring for a client who is receiving IV fluid
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replacement therapy for dehydration. Which of the following \| \| \| \| \| \| \| \|


laboratory results indicates effectiveness of the treatment
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A. Sodium 165 mEq/L
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B. Potassium 5.2 mEq/L
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C. Urine specific gravity 1.020
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D. Hct 62% - CORRECT ANSWERS ✔✔C Urine specific gravity
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1.020
Within the expected range of 1.005-1.030
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A nurse is monitoring the laboratory findings for a client who is
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postoperative following a total hip arthroplasty 6 hr ago. Which of \| \| \| \| \| \| \| \| \| \|


the following values indicates that the client has an increased
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risk for bleeding
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A. PT 11.5 seconds
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B. aPTT 35 seconds
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C. Platelets 80,000
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D. RBC 4.0 million - CORRECT ANSWERS ✔✔C Platelets 80,000
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,platelet range is 150,000-400,000
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A nurse is admitting a client who has a cervical spinal cord injury
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following a motor vehicle crash. Which of the following
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interventions is the nurse's priority while caring for this client
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A. Change the client's position every 2 hours
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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
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D. Assist the client with quad coughing - CORRECT ANSWERS
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✔✔D Assist the client with quad coughing
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The greatest risk to a client who has a cervical spinal cord injury
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is an obstructed airway; the priority is to ensure the client can
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clear their airway. Apply abdominal pressure as the client coughs
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(quad coughing) \|




A nurse is caring for a client who is receiving a blood
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transfusion. Which of the following findings indicates that the
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client is experiencing transfusion-associated circulatory overload
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A. Nasuea
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B. Hypothermia
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C. Dyspnea
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D. Bradycardia - CORRECT ANSWERS ✔✔C Dyspnea
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Dyspnea is an indication of possible transfusion associated
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circulatory overload, leading to hypertension, bounding pulses,
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and confusion. Dyspnea can also indicate transfusion related
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, acute lung injury to an anaphylactic response, which also causes
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wheezing, chest tightness, cyanosis, and low BP \| \| \| \| \| \|




A nurse is assessing a client who has lung cancer and is
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undergoing radiation therapy to the chest. Which of the \| \| \| \| \| \| \| \| \|


following indicates an adverse effect of the therapy
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A. Hair loss on the scalp
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B. Sweating at the treatment site
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C. Altered taste sensations
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D. Intolerance to cold - CORRECT ANSWERS ✔✔C Altered taste
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sensations
Altered taste is a result of the release of metabolites by dead
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cells


A nurse is preparing to administer a unit of packed RBCs to a
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client who has anemia. Which of the following actions should the
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nurse plan to take (select all that apply)
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A. Obtain pre-transfusion temperature
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B. Prime the IV tubing with lactated Ringer's
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C. Instruct an assistive personnel to monitor the client during
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the transfusion
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D. Verify the client's blood type with a second nurse
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E. Use a 20 gauge IV needle for venous access - CORRECT
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ANSWERS ✔✔A, D, E \| \| \|




A, complete assessment prior to transfusion
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