ATI CAPSTONE Medical Surgical Assessment 1- LATEST correct and verified Answers- WITH EXPLANATION

Med Surg Assessment 1 1. 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 i. Use electronic tablet, computer, programmable speech generating device, alphabet board, pencil and paper, etc. 2. 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. Urine specific gravity 1.020 i. Within the expected range of 1.005 – 1.030 3. A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hours ago. Which of the following values indicates that the client has an increased risk for bleeding? a. Platelets 80,000 i. Platelet range is 150,000 – 400,000 4. A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle accident. Which of the following interventions is the nurse’s priority while caring for this client? a. Assist the client with quad coughing i. The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure that the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing). 5. 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. Dyspnea i. 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.