ATI CAPSTONE MEDICAL SURGICAL PROCTORED VERSION 1
AND 2 - COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: A nurse is providing teaching to a client who has
venous insufficiency. Which of the following statements by the
client indicates an understanding of the teaching
A. "I will wear my graduated compression stockings while sleeping"
B. "I will elevate my legs for 10 minutes 3 times per day"
C. "I will limit the time I spend sitting down during the day"
D. "I will cross my legs at my knees when sitting"
Answer:
C) "I will limit the time I spend sitting down during the day"
Avoid prolonged periods of sitting or standing, which keeps the legs from
being in a dependent position and helps prevent venous stasis
Question 2: A nurse is providing teaching to a client who is
undergoing radiation therapy and wants to go for a walk outside.
Which of the following recommendations should the nurse include
in the teaching?
A. "Try to avoid sun exposure by waiting until after sunset to go
outdoors"
B. "Gently was the irradiated area to remove the markings before
going outside"
C. "Protect exposed skin with an over the counter sunscreen"
D. "Wear form sitting clothing when going outside"
Answer:
A) "Try to avoid sun exposure by waiting until after sunset to go
outdoors"
,Protect the skin from exposure to sunlight during treatment and for 1
year after the last treatment. Stay in the shade, go outside in the early
morning or evening to avoid the more intense sun rays to allow the pt to
stay outside for a longer period
Question 3: A nurse in an emergency department is monitoring a
client who reports angina. Which of the following findings should
indicate to the nurse that the client might have experienced a
myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL
Answer:
A ) Increased troponin
Troponin is a myocardial muscle protein released into the blood stream
as a result of injury to the heart muscle. Troponin levels increase within
2-3 hr following an MI
Question 4: A nurse is preparing to obtain blood cultures from a
client's central venous catheter (CVC). Which of the following
actions should the nurse take when accessing the catheter
A. Flush the lumen with heparin solution before each use
B. Aspirate for blood return prior to each use
C. Perform a 5 second scrub to the catheter hub before accessing the
catheter
D. Apply firm pressure to the syringe plunger when flushing the lumen
Answer:
,B) Aspirate for blood return prior to each use
Question 5: A nurse on a medical surgical unit has received shift
report for a group of clients. Which of the following interventions
should the nurse plan to complete first
A. Perform a dressing change on a client who is 24 hr postoperative
following abdominal surgery and has sanguineous drainage on the
dressing
B. Replace an infiltrated IV for a client who has pneumonia and has
scheduled IV antibiotics due in 30 minutes
C. administer a prescribed opioid pain medication to a client who is
reporting back pain as a 5 on a numeric pain scale of 0 to 10
D. Assess a client who is 4hr postoperative following thoracic surgery
and has a respiratory rate of 7/min
Answer:
D) Assess a client who is 4hr postoperative following thoracic surgery
and has a respiratory rate of 7/min
Using the ABC approach, this is the priority. A RR of 7 indicates
hypoventilation and can indicate respiratory failure or shock, especially
in pt who is postop.
Question 6: A nurse on a medical unit is planning care for a client
who has COPD. Which of the following actions should the nurse
include in the plan
A. Suction the client's airway every 4 hours
B. Limit the client's fluid intake to control secretions
C. Provide the client with a high protein diet
D. Administer the client's bronchodilator following each meal
Answer:
, C) Provide the client with a high protein diet
COPD needs a diet high in protein and calories. They should eat
freuqent, small meals and should avoid drinking fluids prior to or during
meals
Question 7: A nurse is administering parenteral nutrition to a client
who has a history of heart failure. Which of the following
manifestations indicates to the nurse that the client is experiencing
fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss
Answer:
C
when the client is recumbent, the extracellular fluid enters the vascular
system and increases the blood volume filtering through the kidneys,
which increases urine production
A, hypertension indicates fluid overload in a pt with heart failure
B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume
overload in a client who has heart failure
Question 8: A nurse is teaching the caregiver of a client who has
mild alzheimer's disease about progression of the disease. Which
of the following should the nurse include as a manifestation of
moderate alzheimer's disease
A. Short term memory loss
AND 2 - COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: A nurse is providing teaching to a client who has
venous insufficiency. Which of the following statements by the
client indicates an understanding of the teaching
A. "I will wear my graduated compression stockings while sleeping"
B. "I will elevate my legs for 10 minutes 3 times per day"
C. "I will limit the time I spend sitting down during the day"
D. "I will cross my legs at my knees when sitting"
Answer:
C) "I will limit the time I spend sitting down during the day"
Avoid prolonged periods of sitting or standing, which keeps the legs from
being in a dependent position and helps prevent venous stasis
Question 2: A nurse is providing teaching to a client who is
undergoing radiation therapy and wants to go for a walk outside.
Which of the following recommendations should the nurse include
in the teaching?
A. "Try to avoid sun exposure by waiting until after sunset to go
outdoors"
B. "Gently was the irradiated area to remove the markings before
going outside"
C. "Protect exposed skin with an over the counter sunscreen"
D. "Wear form sitting clothing when going outside"
Answer:
A) "Try to avoid sun exposure by waiting until after sunset to go
outdoors"
,Protect the skin from exposure to sunlight during treatment and for 1
year after the last treatment. Stay in the shade, go outside in the early
morning or evening to avoid the more intense sun rays to allow the pt to
stay outside for a longer period
Question 3: A nurse in an emergency department is monitoring a
client who reports angina. Which of the following findings should
indicate to the nurse that the client might have experienced a
myocardial infarction (MI)
A. Increased troponin
B. Decreased creatinine kinase MB
C. Cholesterol 300 mg/dL
D. C- reactive protein 1.2 mg/dL
Answer:
A ) Increased troponin
Troponin is a myocardial muscle protein released into the blood stream
as a result of injury to the heart muscle. Troponin levels increase within
2-3 hr following an MI
Question 4: A nurse is preparing to obtain blood cultures from a
client's central venous catheter (CVC). Which of the following
actions should the nurse take when accessing the catheter
A. Flush the lumen with heparin solution before each use
B. Aspirate for blood return prior to each use
C. Perform a 5 second scrub to the catheter hub before accessing the
catheter
D. Apply firm pressure to the syringe plunger when flushing the lumen
Answer:
,B) Aspirate for blood return prior to each use
Question 5: A nurse on a medical surgical unit has received shift
report for a group of clients. Which of the following interventions
should the nurse plan to complete first
A. Perform a dressing change on a client who is 24 hr postoperative
following abdominal surgery and has sanguineous drainage on the
dressing
B. Replace an infiltrated IV for a client who has pneumonia and has
scheduled IV antibiotics due in 30 minutes
C. administer a prescribed opioid pain medication to a client who is
reporting back pain as a 5 on a numeric pain scale of 0 to 10
D. Assess a client who is 4hr postoperative following thoracic surgery
and has a respiratory rate of 7/min
Answer:
D) Assess a client who is 4hr postoperative following thoracic surgery
and has a respiratory rate of 7/min
Using the ABC approach, this is the priority. A RR of 7 indicates
hypoventilation and can indicate respiratory failure or shock, especially
in pt who is postop.
Question 6: A nurse on a medical unit is planning care for a client
who has COPD. Which of the following actions should the nurse
include in the plan
A. Suction the client's airway every 4 hours
B. Limit the client's fluid intake to control secretions
C. Provide the client with a high protein diet
D. Administer the client's bronchodilator following each meal
Answer:
, C) Provide the client with a high protein diet
COPD needs a diet high in protein and calories. They should eat
freuqent, small meals and should avoid drinking fluids prior to or during
meals
Question 7: A nurse is administering parenteral nutrition to a client
who has a history of heart failure. Which of the following
manifestations indicates to the nurse that the client is experiencing
fluid overload
A. hypotension
B. flattened neck veins
C. nocturia
D. weight loss
Answer:
C
when the client is recumbent, the extracellular fluid enters the vascular
system and increases the blood volume filtering through the kidneys,
which increases urine production
A, hypertension indicates fluid overload in a pt with heart failure
B, distended neck veins indicates fluid overload in a pt with heart failure
D, acute weight gain is the most reliable indicator of fluid volume
overload in a client who has heart failure
Question 8: A nurse is teaching the caregiver of a client who has
mild alzheimer's disease about progression of the disease. Which
of the following should the nurse include as a manifestation of
moderate alzheimer's disease
A. Short term memory loss
