Capstone ATI NCLEX Medical Surgical Assessment 1

Capstone.ATI.NCLEX.Medical.Surgical.Asses
sment.1

A.nurse.is.teaching.a.client.how.to.administer.a.medication.using.an.inhaler.with.a.spacer..Whi
ch.of.the.following.instructions.should.the.nurse.include


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".-.......ANSWER.-.....-...D..)."Shake.the.inhaler.vigor
ously.prior.to.use"
Thoroughly.shake.the.inhaler.to.disperse.the.medication.because.the.medication.in.the.inhaler.
can.separate.easily




A.nurse.is.planning.care.for.a.client.who.is.receiving.mechanical.ventilation..Which.of.the.follo
wing.actions.should.the.nurse.include.in.the.plan


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.-.......ANSWER.-.....-...A.).Provide.the.client.with
.a.means.of.communication

,Use.electronic.tablet.computer,.programmable.speech.generating.device,.alphabet.board,.penc
il.and.paper,.etc




A.nurse.is.caring.for.a.client.who.is.receiving.IV.fluid.replacement.therapy.for.dehydration..Whi
ch.of.the.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%.-.......ANSWER.-.....-...C.Urine.specific.gravity.1.020
Within.the.expected.range.of.1.005-1.030




A.nurse.is.monitoring.the.laboratory.findings.for.a.client.who.is.postoperative.following.a.total.
hip.arthroplasty.6.hr.ago..Which.of.the.following.values.indicates.that.the.client.has.an.increas
ed.risk.for.bleeding


A..PT.11.5.seconds
B..aPTT.35.seconds
C..Platelets.80,000
D..RBC.4.0.million.-.......ANSWER.-.....-...C.Platelets.80,000
platelet.range.is.150,000-400,000

, A.nurse.is.admitting.a.client.who.has.a.cervical.spinal.cord.injury.following.a.motor.vehicle.cras
h..Which.of.the.following.interventions.is.the.nurse's.priority.while.caring.for.this.client


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.-.......ANSWER.-.....-...D.Assist.the.client.with.quad.cough
ing
The.greatest.risk.to.a.client.who.has.a.cervical.spinal.cord.injury.is.an.obstructed.airway;.the.pr
iority.is.to.ensure.the.client.can.clear.their.airway..Apply.abdominal.pressure.as.the.client.coug
hs.(quad.coughing)




A.nurse.is.caring.for.a.client.who.is.receiving.a.blood.transfusion..Which.of.the.following.findin
gs.indicates.that.the.client.is.experiencing.transfusion-associated.circulatory.overload


A..Nasuea
B..Hypothermia
C..Dyspnea
D..Bradycardia.-.......ANSWER.-.....-...C.Dyspnea
Dyspnea.is.an.indication.of.possible.transfusion.associated.circulatory.overload,.leading.to.hyp
ertension,.bounding.pulses,.and.confusion..Dyspnea.can.also.indicate.transfusion.related.acute.
lung.injury.to.an.anaphylactic.response,.which.also.causes.wheezing,.chest.tightness,.cyanosis,.
and.low.BP




A.nurse.is.assessing.a.client.who.has.lung.cancer.and.is.undergoing.radiation.therapy.to.the.ch
est..Which.of.the.following.indicates.an.adverse.effect.of.the.therapy