7/6/24, 12:31 AM ATI Capstone Adult Medical Surgical Assessment 2
ATI Capstone Adult Medical Surgical Assessment 2
1. 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
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
2. 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
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 finger between the jacket and the skin with ease = B
3. 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
Limit caffeinated drinks to two per day
Drink fluids during meal time
The nurse should instruct the client to consume high-calorie, high-protein foods to provide energy and
prevent weight loss = B
4. 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
Droplet precautions
Protective environment
1
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, 7/6/24, 12:31 AM ATI Capstone Adult Medical Surgical Assessment 2
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 filtration. 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
5. 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?
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
6. 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?
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
7. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of
the following findings should the nurse notify the provider?
The dressing was changed 7 days ago
The catheter has not been used in 8 hr
The catheter has been flushed 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 finding = B
2
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ATI Capstone Adult Medical Surgical Assessment 2
1. 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
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
2. 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
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 finger between the jacket and the skin with ease = B
3. 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
Limit caffeinated drinks to two per day
Drink fluids during meal time
The nurse should instruct the client to consume high-calorie, high-protein foods to provide energy and
prevent weight loss = B
4. 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
Droplet precautions
Protective environment
1
about:blank 1/15
, 7/6/24, 12:31 AM ATI Capstone Adult Medical Surgical Assessment 2
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 filtration. 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
5. 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?
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
6. 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?
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
7. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of
the following findings should the nurse notify the provider?
The dressing was changed 7 days ago
The catheter has not been used in 8 hr
The catheter has been flushed 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 finding = B
2
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