ATI CAPSTONE MEDICAL SURGICAL
ASSESSMENT 1 AND CORRECT DETAILED
ANSWERS WITH RATIONALES
A nurse is reviewing the laboratory findings for a client who is dehydrated.
| | | | | | | | | | | |
Which of the following BUN levels should the nurse expect
| | | | | | | | | |
A. 3.6 mg/dl |
B. 8 mg/dL |
C. 18.7 mg/dL |
D. 26 mg/dL - ANSWER-D 26 mg/dL
| | | | |
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 conditions in which blood is reabsorbed from injured
| | | | | | | | | | | |
tissues
|
A nurse is reviewing ECG strips for several clients. Which of the following
| | | | | | | | | | | |
images should the nurse identify as atrial 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 - ANSWER-A.) multiple
| | | | | | | | | | |
irregular and variable waves at the baseline and irregular R to R intervals
| | | | | | | | | | | | |
A nurse is preparing to admit a client who has a new tracheostomy from the
| | | | | | | | | | | | | |
operating room. Which of the following items is the priority for the nurse to
| | | | | | | | | | | | | |
have available in the client's room upon admission
| | | | | | | |
A. Obturator
B. Hydrogen peroxide |
C. Sterile gloves |
D. Inner cannula - ANSWER-A.) Obturator
| | | |
The obturator can be inserted in the stoma in the even of dislodgment or
| | | | | | | | | | | | |
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 considered an emergency
| | | | |
A nurse is caring for a client who had a below the knee 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" - ANSWER-A .) "Tell me how the changes to your leg
| | | | | | | | | | | | |
make you feel"
| | |
A nurse in an endoscopy clinic is providing teaching to a client who is to
| | | | | | | | | | | | | |
undergo a colonoscopy for colon cancer screening. Which of the following
| | | | | | | | | | |
information should the nurse provide
| | | | |
A. "You should have nothing to eat or drink for 3 hours prior to the
| | | | | | | | | | | | |
procedure"
|
B. "You should drink the bowel preparation slowly to prevent nausea"
| | | | | | | | |
C. "You will have no discomfort following the procedure"
| | | | | | |
D. "You will need someone to drive you home after your procedure" -
| | | | | | | | | | |
ANSWER-D.) "You will need someone to drive you home after your
| | | | | | | | | | |
procedure"
|
Do not drive for 12-18 hours following the procedure, because during a
| | | | | | | | | | |
colonoscopy, the pt receives moderate sedation
| | | | | |
, A nurse is monitoring a client who is receiving moderate sedation with
| | | | | | | | | | |
midazolam. Which of the following findings requires immediate intervention
| | | | | | | | |
by the nurse
| | |
A. Oxygen saturation 90% | |
B. No response to verbal stimuli
| | | |
C. Occasional premature ventricular contractions (PVCs) | | | |
D. Nausea - ANSWER-B) No response to verbal stimuli | | | | | | |
using urgent vs non-urgent approach, this is the priority. During moderate
| | | | | | | | | |
sedation, the pt should be able to provide a response to questions and
| | | | | | | | | | | | |
commands. No response to verbal stimuli can indicate a loss or
| | | | | | | | | | |
consciousness or oversedation
| | |
A nurse is reviewing the laboratory findings for a client who has heart failure
| | | | | | | | | | | | |
and is taking furosemide. The nurse should identify which of the following
| | | | | | | | | | | |
findings as an adverse effect of the medication
| | | | | | | |
A. Sodium 142 mEq/L | |
B. Metabolic acidosis |
C. Potassium 3.2 mEq/L | |
D. Hypoglycemia - ANSWER-C. Potassium 3.2 mEq/L | | | | |
Loop diuretics remove excessive extracellular fluid through the kidneys,
| | | | | | | |
causing an increased excretion of potassium. Monitor for dysrhythmias
| | | | | | | | |
ASSESSMENT 1 AND CORRECT DETAILED
ANSWERS WITH RATIONALES
A nurse is reviewing the laboratory findings for a client who is dehydrated.
| | | | | | | | | | | |
Which of the following BUN levels should the nurse expect
| | | | | | | | | |
A. 3.6 mg/dl |
B. 8 mg/dL |
C. 18.7 mg/dL |
D. 26 mg/dL - ANSWER-D 26 mg/dL
| | | | |
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 conditions in which blood is reabsorbed from injured
| | | | | | | | | | | |
tissues
|
A nurse is reviewing ECG strips for several clients. Which of the following
| | | | | | | | | | | |
images should the nurse identify as atrial 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 - ANSWER-A.) multiple
| | | | | | | | | | |
irregular and variable waves at the baseline and irregular R to R intervals
| | | | | | | | | | | | |
A nurse is preparing to admit a client who has a new tracheostomy from the
| | | | | | | | | | | | | |
operating room. Which of the following items is the priority for the nurse to
| | | | | | | | | | | | | |
have available in the client's room upon admission
| | | | | | | |
A. Obturator
B. Hydrogen peroxide |
C. Sterile gloves |
D. Inner cannula - ANSWER-A.) Obturator
| | | |
The obturator can be inserted in the stoma in the even of dislodgment or
| | | | | | | | | | | | |
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 considered an emergency
| | | | |
A nurse is caring for a client who had a below the knee 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" - ANSWER-A .) "Tell me how the changes to your leg
| | | | | | | | | | | | |
make you feel"
| | |
A nurse in an endoscopy clinic is providing teaching to a client who is to
| | | | | | | | | | | | | |
undergo a colonoscopy for colon cancer screening. Which of the following
| | | | | | | | | | |
information should the nurse provide
| | | | |
A. "You should have nothing to eat or drink for 3 hours prior to the
| | | | | | | | | | | | |
procedure"
|
B. "You should drink the bowel preparation slowly to prevent nausea"
| | | | | | | | |
C. "You will have no discomfort following the procedure"
| | | | | | |
D. "You will need someone to drive you home after your procedure" -
| | | | | | | | | | |
ANSWER-D.) "You will need someone to drive you home after your
| | | | | | | | | | |
procedure"
|
Do not drive for 12-18 hours following the procedure, because during a
| | | | | | | | | | |
colonoscopy, the pt receives moderate sedation
| | | | | |
, A nurse is monitoring a client who is receiving moderate sedation with
| | | | | | | | | | |
midazolam. Which of the following findings requires immediate intervention
| | | | | | | | |
by the nurse
| | |
A. Oxygen saturation 90% | |
B. No response to verbal stimuli
| | | |
C. Occasional premature ventricular contractions (PVCs) | | | |
D. Nausea - ANSWER-B) No response to verbal stimuli | | | | | | |
using urgent vs non-urgent approach, this is the priority. During moderate
| | | | | | | | | |
sedation, the pt should be able to provide a response to questions and
| | | | | | | | | | | | |
commands. No response to verbal stimuli can indicate a loss or
| | | | | | | | | | |
consciousness or oversedation
| | |
A nurse is reviewing the laboratory findings for a client who has heart failure
| | | | | | | | | | | | |
and is taking furosemide. The nurse should identify which of the following
| | | | | | | | | | | |
findings as an adverse effect of the medication
| | | | | | | |
A. Sodium 142 mEq/L | |
B. Metabolic acidosis |
C. Potassium 3.2 mEq/L | |
D. Hypoglycemia - ANSWER-C. Potassium 3.2 mEq/L | | | | |
Loop diuretics remove excessive extracellular fluid through the kidneys,
| | | | | | | |
causing an increased excretion of potassium. Monitor for dysrhythmias
| | | | | | | | |
