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1 & 2 ALL 100 QUESTIONS
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g CORRECT FULLY EXPLAINED SOLUTIONS AND RATIONALE g g g g g
THE NEWEST EDITION g gg
Capstone ATI NCLEX Medical Surgical Assessment 1
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A nurse is teaching a client how to administer a medication using an inhaler with a spa
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cer. Which of the following instructions should the nurse include
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A. "Wait at least 5 minutes between puffs from the same inhaler"
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B. "Breathe in rapidly when inhaling the medication"
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C. "Clean the plastic inhaler cap weekly with cold water"
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D. "Shake the inhaler vigorously prior to use" - ANSWER-
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D .) "Shake the inhaler vigorously prior to use"
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Thoroughly shake the inhaler to disperse the medication because the medication in th
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e inhaler can separate easily
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,A nurse is planning care for a client who is receiving mechanical ventilation. Which
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of the following actions should the nurse include in the plan
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A. Provide the client with a means of communication
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B. Maintain the head of the client's bed in a flat position
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C. Suction the client's endotracheal tube every 4 hr
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D. Perform oral hygiene for the client every 8 hr - ANSWER-
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A.) Provide the client with a means of communication
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Use electronic tablet computer, programmable speech generating device, alphabet bo
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ard, pencil and paper, etc
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A nurse is caring for a client who is receiving IV fluid replacement therapy for dehy
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dration. Which of the following laboratory results indicates effectiveness of the treat
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ment
A. Sodium 165 mEq/L g g
B. Potassium 5.2 mEq/L g g
C. Urine specific gravity 1.020
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D. Hct 62% - ANSWER-
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,C Urine specific gravity 1.020 Within the expected range
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g of 1.005-1.030
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A nurse is monitoring the laboratory findings for a client who is postoperative follow
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ing a total hip arthroplasty 6 hr ago. Which of the following values indicates that the cl
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ient has an increased risk for bleeding
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A. PT 11.5 seconds g g
B. aPTT 35 seconds g g
C. Platelets 80,000 g
D. RBC 4.0 million - ANSWER- g g g g
C Platelets 80,000 platelet range is 150,000-400,000
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A nurse is admitting a client who has a cervical spinal cord injury following a motor v
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ehicle crash. Which of the following interventions is the nurse's priority while caring
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for this client
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A. Change the client's position every 2 hoursg g g g g g
B. Pad pressure points at the edges of the client's cervical collar
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C. Palpate the client's abdomen for bladder distention
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, D. Assist the client with quad coughing - ANSWER-
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D Assist the client with quad coughing
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The greatest risk to a client who has a cervical spinal cord injury is an obstructed airw
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ay; the priority is to ensure the client can clear their airway. Apply abdominal pressur
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e as the client coughs (quad coughing)
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A nurse is caring for a client who is receiving a blood transfusion. Which of the follo
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wing findings indicates that the client is experiencing transfusion-
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associated circulatory overload g g
A. Nasuea
B. Hypothermia
C. Dyspnea
D. Bradycardia - ANSWER-C Dyspnea g g g
Dyspnea is an indication of possible transfusion associated circulatory overload, lea
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ding to hypertension, bounding pulses, and confusion. Dyspnea can also indicate tra
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nsfusion related acute lung injury to an anaphylactic response, which also causes wh
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eezing, chest tightness, cyanosis, and low BP
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A nurse is assessing a client who has lung cancer and is undergoing radiation th
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