ATI CAPSTONE ADULT MEDICAL SURGICAL ASSESSMENT 2

ATI Capstone Adult Medical Surgical Assessment 2 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 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? Inspect the pin site every 4 hr Monitor the client’s skin under the halo vest Ensure two personnel hold the halo device when repositioning the client Apply powder frequently to the client’s skin under the vest to decrease itching The nurse should monitor the client’s skin that is under the halo vest for excessive sweating, redness, or blistering which can lead to skin breakdown and infection. To ensure the vest is not causing pressure, the nurse should be able to insert one 昀椀nger between the jacket and the skin with ease = B A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include? Eat three large meals daily Consume high-calorie foods Limit ca昀昀einated drinks to two per day Drink 昀氀uids during meal time The nurse should instruct the client to consume high-calorie, high-protein foods to provide energy and prevent weight loss = B 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? Contact precautions Airborne precautions Droplet precautions Protective environment 1 Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has TB under airborne precautions to prevent the spread of microbes. For airborne precautions, the client should be placed in a private, negative pressure room with 6 – 12 air exchanges per hour with HEPA 昀椀ltration. The nurse should wear an N95 respirator while providing care to the client. Nurse should also teach client to cough and expectorate sputum into tissues, which are disposed of in a waterproof sack = B 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? Propofol Pancuronium Promethazine Pentoxifylline The nurse should identify that propofol is a short-acting anesthetic medication that can be used to cause moderate sedation for procedures, such as a colonoscopy = A 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? Early menopause History of falls African American race Obesity A client who goes into early menopause, form natural or surgical causes, is at a greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Decreased estrogen leads to an increase in bone decay & decrease in the production of osteoclasts that produce new bone. Osteoporosis is the most common metabolic bone disorder that results in low bone density. It occurs when the rate of bone resorption exceeds the rate of bone formation, resulting in fragile bone tissue and subsequent fractures = A A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following 昀椀ndings should the nurse notify the provider? The dressing was changed 7 days ago The circumference of the client’s upper arm has increased by 10% The catheter has not been used in 8 hr The catheter has been 昀氀ushed with 10 mL of sterile saline after medication use Circumference of the upper arm above the insertion site of the PICC should be measured at the time of insertion & then again during assessments. An increase in the circumference could indicate deep vein thrombosis, which could be life threatening. The nurse should contact the provider immediately about this 昀椀nding = B 2 A nurse is reviewing the medical record of a client who has unstable angina. Which of the following 昀椀ndings 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 100 units/L C-reactive protein 0.8 mg/dL Myoglobin 88 mcg/L Breath sounds Temperature Blood pressure Creatinine kinase The nurse should identify that the client has manifestations of le昀琀 ventricular failure & pulmonary edema due to decreased cardiac output & reduced cardiac perfusion. These manifestations include cool, clammy skin; pallor; decreased urine output; decreased peripheral pulses; tachypnea; tachycardia; and crackles heard in the bases of the lungs. The client is at risk for cariogenic shock, so the nurse should report these 昀椀ndings to the provider immediately = A A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority? Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10 Administer oxygen to a client who has an oxygen saturation of 91% Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery