ATI Capstone MS Assessment 2
A nurse is a caring for client who is postoperative following a below-the-knee amputation. Which of the
following actions should the nurse take *** Place the client prone for 20 min every 3 hr. (reduce risk for
hip contractures)
A nurse is caring for a client who has a history of tonic-clonic seizures. Which of the following
precautions should the nurse take (Select all that apply.) *** Keep a suction apparatus at the bedside,
Keep the bed in the lowest position., Keep oxygen equipment at the bedside.
A nurse is creating a plan of care for a client who has meningitis. Which of the following interventions
should the nurse include *** Keep the client's environment dark and quiet.
A nurse is receiving a report on a group of clients. Which of the following clients should the nurse assess
first *** A client who has a systemic infection and an oral temperature of 39.1° C (102.4°
A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following
clients should the nurse identify as being at an increased risk for hepatitis A *** A client who has
recently done volunteer work in a developing country
(Hepatitis A is most frequently acquired through infected water or food sources. These conditions are
often found in developing countries.)
A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should
the nurse include *** Educate the client on pursed-lip breathing.
A nurse is reviewing a client's medical record prior to administering furosemide via IV bolus to a client
who has heart failure. For which of the following findings should the nurse withhold the medication and
notify the provider *** Hypokalemia
, A nurse is caring for a client who has renal failure. Which of the following arterial blood gas (ABG) results
should the nurse expect *** pH 7.25, HCOg* 20 mEq/L, PaCOz 35 mm Hg
(A client who has renal failure will manifest metabolic acidosis (low HCO3-, low pH) related to an
inability of the renal tubules to secrete hydrogen ions and a decrease in bicarbonate levels. In response,
the client's respiratory system attempts to compensate through hyperventilation to reduce PaCO2.
Expected reference ranges for ABG findings include the following: pH 7.35 to 7.45, HCO3- 22 to 26
mEq/L, and PaCO2 35 to 45 mm Hg.)
A nurse is providing teaching for a client who has Parkinson's disease and a new prescription for
selegiline. Which of the following statements should the nurse include *** "Avoid eating aged cheeses
or smoked meats while taking this medication."
A nurse is instructing a client's caregiver on how to position the client before administering tube
feedings in the home. Which of the following statements by the caregiver demonstrates an
understanding of the teaching *** "I will sit him up in bed."
A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following
statements should the nurse include in the teaching *** "Stress can activate an outbreak."
A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following
information should the nurse include *** "Watch for a decreased heart rate while using this
medication."
A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal.
Which of the following actions is the nurse's priority *** Monitor blood pressure.
A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following
instructions should the nurse include in the teaching *** "It is important to develop a daily schedule
that reduces fatigue and conserves energy."
A nurse is a caring for client who is postoperative following a below-the-knee amputation. Which of the
following actions should the nurse take *** Place the client prone for 20 min every 3 hr. (reduce risk for
hip contractures)
A nurse is caring for a client who has a history of tonic-clonic seizures. Which of the following
precautions should the nurse take (Select all that apply.) *** Keep a suction apparatus at the bedside,
Keep the bed in the lowest position., Keep oxygen equipment at the bedside.
A nurse is creating a plan of care for a client who has meningitis. Which of the following interventions
should the nurse include *** Keep the client's environment dark and quiet.
A nurse is receiving a report on a group of clients. Which of the following clients should the nurse assess
first *** A client who has a systemic infection and an oral temperature of 39.1° C (102.4°
A nurse is discussing risk factors for hepatitis A with a newly licensed nurse. Which of the following
clients should the nurse identify as being at an increased risk for hepatitis A *** A client who has
recently done volunteer work in a developing country
(Hepatitis A is most frequently acquired through infected water or food sources. These conditions are
often found in developing countries.)
A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should
the nurse include *** Educate the client on pursed-lip breathing.
A nurse is reviewing a client's medical record prior to administering furosemide via IV bolus to a client
who has heart failure. For which of the following findings should the nurse withhold the medication and
notify the provider *** Hypokalemia
, A nurse is caring for a client who has renal failure. Which of the following arterial blood gas (ABG) results
should the nurse expect *** pH 7.25, HCOg* 20 mEq/L, PaCOz 35 mm Hg
(A client who has renal failure will manifest metabolic acidosis (low HCO3-, low pH) related to an
inability of the renal tubules to secrete hydrogen ions and a decrease in bicarbonate levels. In response,
the client's respiratory system attempts to compensate through hyperventilation to reduce PaCO2.
Expected reference ranges for ABG findings include the following: pH 7.35 to 7.45, HCO3- 22 to 26
mEq/L, and PaCO2 35 to 45 mm Hg.)
A nurse is providing teaching for a client who has Parkinson's disease and a new prescription for
selegiline. Which of the following statements should the nurse include *** "Avoid eating aged cheeses
or smoked meats while taking this medication."
A nurse is instructing a client's caregiver on how to position the client before administering tube
feedings in the home. Which of the following statements by the caregiver demonstrates an
understanding of the teaching *** "I will sit him up in bed."
A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following
statements should the nurse include in the teaching *** "Stress can activate an outbreak."
A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following
information should the nurse include *** "Watch for a decreased heart rate while using this
medication."
A nurse is caring for a client who is postoperative immediately following a pheochromocytoma removal.
Which of the following actions is the nurse's priority *** Monitor blood pressure.
A nurse is providing discharge teaching to a client who has multiple sclerosis. Which of the following
instructions should the nurse include in the teaching *** "It is important to develop a daily schedule
that reduces fatigue and conserves energy."
