Capstone ATI NCLEX Medical Surgical Assessment 1, ATI Capstone Adult Medical Surgical Assessment 2
A nurse is teaching a client how to administer a medication D .) "Shake the inhaler vigorously prior to use"
using an inhaler with a spacer. Which of the following Thoroughly shake the inhaler to disperse the medication because the medication in
instructions should the nurse include the inhaler can separate easily
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"
A nurse is planning care for a client who is receiving A.) Provide the client with a means of communication
mechanical ventilation. Which of the following actions
should the nurse include in the plan Use electronic tablet computer, programmable speech generating device, alphabet
board, pencil and paper, etc
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
A nurse is caring for a client who is receiving IV fluid C Urine specific gravity 1.020
replacement therapy for dehydration. Which of the Within the expected range of 1.005-1.030
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%
A nurse is monitoring the laboratory findings for a client C Platelets 80,000
who is postoperative following a total hip arthroplasty 6 hr platelet range is 150,000-400,000
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
A nurse is admitting a client who has a cervical spinal cord D Assist the client with quad coughing
injury following a motor vehicle crash. Which of the The greatest risk to a client who has a cervical spinal cord injury is an obstructed
following interventions is the nurse's priority while caring airway; the priority is to ensure the client can clear their airway. Apply abdominal
for this client pressure as the client coughs (quad coughing)
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
A nurse is caring for a client who is receiving a blood C Dyspnea
transfusion. Which of the following findings indicates that Dyspnea is an indication of possible transfusion associated circulatory overload,
the client is experiencing transfusion-associated circulatory leading to hypertension, bounding pulses, and confusion. Dyspnea can also
overload indicate transfusion related acute lung injury to an anaphylactic response, which
also causes wheezing, chest tightness, cyanosis, and low BP
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia
A nurse is assessing a client who has lung cancer and is C Altered taste sensations
undergoing radiation therapy to the chest. Which of the Altered taste is a result of the release of metabolites by dead cells
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
, Capstone ATI NCLEX Medical Surgical Assessment 1, ATI Capstone Adult Medical Surgical Assessment 2
A nurse is preparing to administer a unit of packed RBCs A, D, E
to a client who has anemia. Which of the following actions A, complete assessment prior to transfusion
should the nurse plan to take (select all that apply)
D, verify identification, blood compatibility, and expiration of product with second
A. Obtain pre-transfusion temperature nurse
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the
during the transfusion risk of cell hemolysis and obstruction of flow
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access
A nurse is reviewing the laboratory findings for a client who D 26 mg/dL
is dehydrated. Which of the following BUN levels should
the nurse expect 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
A. 3.6 mg/dl conditions in which blood is reabsorbed from injured tissues
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL
A nurse is reviewing ECG strips for several clients. Which A.) multiple irregular and variable waves at the baseline and irregular R to R
of the following images should the nurse identify as atrial intervals
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
A nurse is preparing to admit a client who has a new A.) Obturator
tracheostomy from the operating room. Which of the
following items is the priority for the nurse to have The obturator can be inserted in the stoma in the even of dislodgment or
available in the client's room upon admission decannulation to maintain an airway until a new trach tube can be placed. For the
first 72 hr following the insertion of a trach, dislodgement or decannulation is
A. Obturator considered an emergency
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula
A nurse is caring for a client who had a below the knee A .) "Tell me how the changes to your leg make you feel"
amputation due to a traumatic injury 2 days ago. Which of
the following statements should the nurse use to assess
how the client is coping with this change in their body
image
A. "Tell me how the changes to your leg make you feel"
B. "What potential changes do you think you'll need to
make when doing your job"
C. "Let's discuss how you can adjust once you have a
prosthesis"
D. "What are some possible issues that you foresee when
completing self-management tasks"
A nurse is teaching a client how to administer a medication D .) "Shake the inhaler vigorously prior to use"
using an inhaler with a spacer. Which of the following Thoroughly shake the inhaler to disperse the medication because the medication in
instructions should the nurse include the inhaler can separate easily
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"
A nurse is planning care for a client who is receiving A.) Provide the client with a means of communication
mechanical ventilation. Which of the following actions
should the nurse include in the plan Use electronic tablet computer, programmable speech generating device, alphabet
board, pencil and paper, etc
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
A nurse is caring for a client who is receiving IV fluid C Urine specific gravity 1.020
replacement therapy for dehydration. Which of the Within the expected range of 1.005-1.030
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%
A nurse is monitoring the laboratory findings for a client C Platelets 80,000
who is postoperative following a total hip arthroplasty 6 hr platelet range is 150,000-400,000
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
A nurse is admitting a client who has a cervical spinal cord D Assist the client with quad coughing
injury following a motor vehicle crash. Which of the The greatest risk to a client who has a cervical spinal cord injury is an obstructed
following interventions is the nurse's priority while caring airway; the priority is to ensure the client can clear their airway. Apply abdominal
for this client pressure as the client coughs (quad coughing)
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
A nurse is caring for a client who is receiving a blood C Dyspnea
transfusion. Which of the following findings indicates that Dyspnea is an indication of possible transfusion associated circulatory overload,
the client is experiencing transfusion-associated circulatory leading to hypertension, bounding pulses, and confusion. Dyspnea can also
overload indicate transfusion related acute lung injury to an anaphylactic response, which
also causes wheezing, chest tightness, cyanosis, and low BP
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia
A nurse is assessing a client who has lung cancer and is C Altered taste sensations
undergoing radiation therapy to the chest. Which of the Altered taste is a result of the release of metabolites by dead cells
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
, Capstone ATI NCLEX Medical Surgical Assessment 1, ATI Capstone Adult Medical Surgical Assessment 2
A nurse is preparing to administer a unit of packed RBCs A, D, E
to a client who has anemia. Which of the following actions A, complete assessment prior to transfusion
should the nurse plan to take (select all that apply)
D, verify identification, blood compatibility, and expiration of product with second
A. Obtain pre-transfusion temperature nurse
B. Prime the IV tubing with lactated Ringer's
C. Instruct an assistive personnel to monitor the client E, the nurse should use a large bore needle to transfuse the PRBCs to reduce the
during the transfusion risk of cell hemolysis and obstruction of flow
D. Verify the client's blood type with a second nurse
E. Use a 20 gauge IV needle for venous access
A nurse is reviewing the laboratory findings for a client who D 26 mg/dL
is dehydrated. Which of the following BUN levels should
the nurse expect 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
A. 3.6 mg/dl conditions in which blood is reabsorbed from injured tissues
B. 8 mg/dL
C. 18.7 mg/dL
D. 26 mg/dL
A nurse is reviewing ECG strips for several clients. Which A.) multiple irregular and variable waves at the baseline and irregular R to R
of the following images should the nurse identify as atrial intervals
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
A nurse is preparing to admit a client who has a new A.) Obturator
tracheostomy from the operating room. Which of the
following items is the priority for the nurse to have The obturator can be inserted in the stoma in the even of dislodgment or
available in the client's room upon admission decannulation to maintain an airway until a new trach tube can be placed. For the
first 72 hr following the insertion of a trach, dislodgement or decannulation is
A. Obturator considered an emergency
B. Hydrogen peroxide
C. Sterile gloves
D. Inner cannula
A nurse is caring for a client who had a below the knee A .) "Tell me how the changes to your leg make you feel"
amputation due to a traumatic injury 2 days ago. Which of
the following statements should the nurse use to assess
how the client is coping with this change in their body
image
A. "Tell me how the changes to your leg make you feel"
B. "What potential changes do you think you'll need to
make when doing your job"
C. "Let's discuss how you can adjust once you have a
prosthesis"
D. "What are some possible issues that you foresee when
completing self-management tasks"
