ATI CAPSTONE MEDICAL SURGICAL
ASSESSMENT 1 & 2 ALL QUESTIONS AND
CORRECT FULLY EXPLAINED SOLUTIONS
AND RATIONALES
Capstone ATI NCLEX Medical Surgical Assessment 1 | | | | | |
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
ASSESSMENT 1 & 2 ALL QUESTIONS AND
CORRECT FULLY EXPLAINED SOLUTIONS
AND RATIONALES
Capstone ATI NCLEX Medical Surgical Assessment 1 | | | | | |
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
