ATI Capstone Adult Medical Surgical
Assessment 2
1. A nurse is teaching a group of assistive personnel (AP) about caring for clients
who have Alzheimer's disease. Which of the following information should the nurse
include in the teaching?
Explain procedures in full detail to client before initiating care
Limit a client's activities to minimize emotional outbursts
Speak clearly and loudly to a client who is unable to form words or sentences
Provide supervision to prevent a client from becoming injured or lost - ANSWER
Provide supervision to prevent a client from becoming injured or lost
A client who has Alzheimer's disease can wander and become lost. The AP should
initiate interventions to keep the client safe, such as redirection, frequent monitoring,
and reorientation. The AP should encourage a client who has Alzheimer's disease to
participate in activities for as long as possible because socializing with others can
provide the client with comfort = D
A nurse is developing a plan of care for a client who will be placed in halo traction
following surgical repair of the cervical spine. Which of the following interventions
should the nurse include in the plan? - ANSWER Monitor the client's skin under the
halo vest
A nurse is providing discharge teaching for a client who has COPD about nutrition.
Which of the following instructions should the nurse include? - ANSWER Consume
high-calorie foods
4. A nurse is caring for a client who has anew diagnosis of tuberculosis. Which of the
following precautions should the nurse initiate to prevent transmission of the
disease? - ANSWER Airborne precautions
5. A nurse is preparing a client for a colonoscopy. Which of the following medications
should the nurse anticipate the provider to prescribe as an anesthetic for the
procedure? - ANSWER Propofol
6. A nurse is teaching a group of clients about the risk factors for osteoporosis.
Which of the following should the nurse include as a risk factor for osteoporosis? -
ANSWER Early menopause
7. A nurse is caring for a client who has a peripherally inserted central catheter
(PICC). For which of the following findings should the nurse notify the provider? -
ANSWER The dressing was changed 7 days ago
8. A nurse is reviewing the medical record of a client who has unstable angina.
Which of the following findings should the nurse report to the provider?
, Exhibit 1 - Graphic record: BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min,
Resp rate 26/min, urine output 90 mL/h hr
Exhibit 2 - Nurse's notes: Skin is cool & moist with pallor need.Bilateral breath
sounds with crackles heard at bases of lungs.
Pedal pulses are present at 1+ bilateral. Exhibit 3 - Diagnostic results: Creatine
kinase - ANSWER Breath sounds
9. A nurse is planning care for a group of postoperative clients. Which of the
following interventions should the nurse identify as the priority? - ANSWER
Administer oxygen to a client who has an oxygen saturation of 91%
10. A nurse is providing discharge teaching to a client who has heart failure and a
prescription for furosemide 20 mg PO two times daily. Which of the following
instructions should the nurse include in the teaching? - ANSWER Increase intake of
high-potassium foods
A nurse is teaching a client who has hypertension about dietary modifications to help
control blood pressure. Which of the following food choices should the nurse
recommend as the best choice for the client to include in their diet? - ANSWER 3 oz
of chicken breast
12. A home health nurse is providing teaching to the family of a client who has a
seizure disorder. Which of the following interventions should the nurse include in the
teaching? - ANSWER Position the client on their side during a seizure
13. A nurse is assessing a client who has meningitis. The nurse should identify
which of the following findings as a positive Kernig's sign? - ANSWER After hip
flexion, the client is unable to extend their leg completely without pain
14. A nurse is assessing a client who has a heart rate of 40/min. The client is
diaphoretic and has chest pain. Which of the following medications should the nurse
plan to administer? - ANSWER Atropine
15. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the
following findings should the nurse expect? - ANSWER Sticky mucous membranes
16. A nurse is caring for a client who has burn injuries covering their upper body and
is concerned about their altered appearance. Which of the following statements
should the nurse make? - ANSWER "It could be helpful for you to attend a support
group for people who have burn injuries."
17. A nurse is teaching a client who has type 1 DM about hypoglycemia. Which of
the following statements by the client indicates an understanding of the teaching? -
ANSWER "I can drink 4 oz of soda if my blood sugar is low."
18. A nurse is assessing a client who has a permanent spinal cord injury and is
scheduled for discharge. Which of the following client statements indicates that the
client is coping effectively? - ANSWER "I would like to play wheelchair basketball.
When I get stronger, I think I'll look for a league."
Assessment 2
1. A nurse is teaching a group of assistive personnel (AP) about caring for clients
who have Alzheimer's disease. Which of the following information should the nurse
include in the teaching?
Explain procedures in full detail to client before initiating care
Limit a client's activities to minimize emotional outbursts
Speak clearly and loudly to a client who is unable to form words or sentences
Provide supervision to prevent a client from becoming injured or lost - ANSWER
Provide supervision to prevent a client from becoming injured or lost
A client who has Alzheimer's disease can wander and become lost. The AP should
initiate interventions to keep the client safe, such as redirection, frequent monitoring,
and reorientation. The AP should encourage a client who has Alzheimer's disease to
participate in activities for as long as possible because socializing with others can
provide the client with comfort = D
A nurse is developing a plan of care for a client who will be placed in halo traction
following surgical repair of the cervical spine. Which of the following interventions
should the nurse include in the plan? - ANSWER Monitor the client's skin under the
halo vest
A nurse is providing discharge teaching for a client who has COPD about nutrition.
Which of the following instructions should the nurse include? - ANSWER Consume
high-calorie foods
4. A nurse is caring for a client who has anew diagnosis of tuberculosis. Which of the
following precautions should the nurse initiate to prevent transmission of the
disease? - ANSWER Airborne precautions
5. A nurse is preparing a client for a colonoscopy. Which of the following medications
should the nurse anticipate the provider to prescribe as an anesthetic for the
procedure? - ANSWER Propofol
6. A nurse is teaching a group of clients about the risk factors for osteoporosis.
Which of the following should the nurse include as a risk factor for osteoporosis? -
ANSWER Early menopause
7. A nurse is caring for a client who has a peripherally inserted central catheter
(PICC). For which of the following findings should the nurse notify the provider? -
ANSWER The dressing was changed 7 days ago
8. A nurse is reviewing the medical record of a client who has unstable angina.
Which of the following findings should the nurse report to the provider?
, Exhibit 1 - Graphic record: BP 106/62 mm Hg, Temp 38°C (100.4°F), HR 112/min,
Resp rate 26/min, urine output 90 mL/h hr
Exhibit 2 - Nurse's notes: Skin is cool & moist with pallor need.Bilateral breath
sounds with crackles heard at bases of lungs.
Pedal pulses are present at 1+ bilateral. Exhibit 3 - Diagnostic results: Creatine
kinase - ANSWER Breath sounds
9. A nurse is planning care for a group of postoperative clients. Which of the
following interventions should the nurse identify as the priority? - ANSWER
Administer oxygen to a client who has an oxygen saturation of 91%
10. A nurse is providing discharge teaching to a client who has heart failure and a
prescription for furosemide 20 mg PO two times daily. Which of the following
instructions should the nurse include in the teaching? - ANSWER Increase intake of
high-potassium foods
A nurse is teaching a client who has hypertension about dietary modifications to help
control blood pressure. Which of the following food choices should the nurse
recommend as the best choice for the client to include in their diet? - ANSWER 3 oz
of chicken breast
12. A home health nurse is providing teaching to the family of a client who has a
seizure disorder. Which of the following interventions should the nurse include in the
teaching? - ANSWER Position the client on their side during a seizure
13. A nurse is assessing a client who has meningitis. The nurse should identify
which of the following findings as a positive Kernig's sign? - ANSWER After hip
flexion, the client is unable to extend their leg completely without pain
14. A nurse is assessing a client who has a heart rate of 40/min. The client is
diaphoretic and has chest pain. Which of the following medications should the nurse
plan to administer? - ANSWER Atropine
15. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the
following findings should the nurse expect? - ANSWER Sticky mucous membranes
16. A nurse is caring for a client who has burn injuries covering their upper body and
is concerned about their altered appearance. Which of the following statements
should the nurse make? - ANSWER "It could be helpful for you to attend a support
group for people who have burn injuries."
17. A nurse is teaching a client who has type 1 DM about hypoglycemia. Which of
the following statements by the client indicates an understanding of the teaching? -
ANSWER "I can drink 4 oz of soda if my blood sugar is low."
18. A nurse is assessing a client who has a permanent spinal cord injury and is
scheduled for discharge. Which of the following client statements indicates that the
client is coping effectively? - ANSWER "I would like to play wheelchair basketball.
When I get stronger, I think I'll look for a league."
