Capstone ATI NCLEX Medical Surgical Assessment 1
Study online at https://quizlet.com/_h1csqy
1. A nurse is teaching a client how to admin- D .) "Shake the inhaler vigorously prior to use"
ister a medication using an inhaler with Thoroughly shake the inhaler to disperse the
a spacer. Which of the following instruc- medication because the medication in the in-
tions should the nurse include haler can separate easily
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"
2. A nurse is planning care for a client who is A.) Provide the client with a means of commu-
receiving mechanical ventilation. Which nication
of the following actions should the nurse
include in the plan Use electronic tablet computer, programma-
ble speech generating device, alphabet board,
A. Provide the client with a means of com- pencil and paper, etc
munication
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
3. A nurse is caring for a client who is re- C Urine specific gravity 1.020
ceiving IV fluid replacement therapy for Within the expected range of 1.005-1.030
dehydration. Which of the following lab-
oratory results indicates effectiveness of
, Capstone ATI NCLEX Medical Surgical Assessment 1
Study online at https://quizlet.com/_h1csqy
the treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%
4. A nurse is monitoring the laboratory find- C Platelets 80,000
ings for a client who is postoperative fol- platelet range is 150,000-400,000
lowing a total hip arthroplasty 6 hr ago.
Which of the following values indicates
that the client has an increased risk for
bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million
5. A nurse is admitting a client who has a D Assist the client with quad coughing
cervical spinal cord injury following a mo- The greatest risk to a client who has a cervical
tor vehicle crash. Which of the following spinal cord injury is an obstructed airway; the
interventions is the nurse's priority while priority is to ensure the client can clear their
caring for this client airway. Apply abdominal pressure as the client
coughs (quad coughing)
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 blad-
der distention
D. Assist the client with quad coughing
, Capstone ATI NCLEX Medical Surgical Assessment 1
Study online at https://quizlet.com/_h1csqy
6. A nurse is caring for a client who is receiv- C Dyspnea
ing a blood transfusion. Which of the fol- Dyspnea is an indication of possible transfu-
lowing findings indicates that the client is sion associated circulatory overload, leading
experiencing transfusion-associated cir- to hypertension, bounding pulses, and con-
culatory overload fusion. Dyspnea can also indicate transfusion
related acute lung injury to an anaphylactic
A. Nasuea response, which also causes wheezing, chest
B. Hypothermia tightness, cyanosis, and low BP
C. Dyspnea
D. Bradycardia
7. A nurse is assessing a client who has lung C Altered taste sensations
cancer and is undergoing radiation ther- Altered taste is a result of the release of
apy to the chest. Which of the following metabolites by dead cells
indicates an adverse effect of the thera-
py
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold
8. A nurse is preparing to administer a A, D, E
unit of packed RBCs to a client who has A, complete assessment prior to transfusion
anemia. Which of the following actions
should the nurse plan to take (select all D, verify identification, blood compatibility, and
that apply) expiration of product with second nurse
A. Obtain pre-transfusion temperature E, the nurse should use a large bore needle to
B. Prime the IV tubing with lactated transfuse the PRBCs to reduce the risk of cell
Ringer's hemolysis and obstruction of flow
C. Instruct an assistive personnel to mon-
itor the client during the transfusion
Study online at https://quizlet.com/_h1csqy
1. A nurse is teaching a client how to admin- D .) "Shake the inhaler vigorously prior to use"
ister a medication using an inhaler with Thoroughly shake the inhaler to disperse the
a spacer. Which of the following instruc- medication because the medication in the in-
tions should the nurse include haler can separate easily
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"
2. A nurse is planning care for a client who is A.) Provide the client with a means of commu-
receiving mechanical ventilation. Which nication
of the following actions should the nurse
include in the plan Use electronic tablet computer, programma-
ble speech generating device, alphabet board,
A. Provide the client with a means of com- pencil and paper, etc
munication
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
3. A nurse is caring for a client who is re- C Urine specific gravity 1.020
ceiving IV fluid replacement therapy for Within the expected range of 1.005-1.030
dehydration. Which of the following lab-
oratory results indicates effectiveness of
, Capstone ATI NCLEX Medical Surgical Assessment 1
Study online at https://quizlet.com/_h1csqy
the treatment
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62%
4. A nurse is monitoring the laboratory find- C Platelets 80,000
ings for a client who is postoperative fol- platelet range is 150,000-400,000
lowing a total hip arthroplasty 6 hr ago.
Which of the following values indicates
that the client has an increased risk for
bleeding
A. PT 11.5 seconds
B. aPTT 35 seconds
C. Platelets 80,000
D. RBC 4.0 million
5. A nurse is admitting a client who has a D Assist the client with quad coughing
cervical spinal cord injury following a mo- The greatest risk to a client who has a cervical
tor vehicle crash. Which of the following spinal cord injury is an obstructed airway; the
interventions is the nurse's priority while priority is to ensure the client can clear their
caring for this client airway. Apply abdominal pressure as the client
coughs (quad coughing)
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 blad-
der distention
D. Assist the client with quad coughing
, Capstone ATI NCLEX Medical Surgical Assessment 1
Study online at https://quizlet.com/_h1csqy
6. A nurse is caring for a client who is receiv- C Dyspnea
ing a blood transfusion. Which of the fol- Dyspnea is an indication of possible transfu-
lowing findings indicates that the client is sion associated circulatory overload, leading
experiencing transfusion-associated cir- to hypertension, bounding pulses, and con-
culatory overload fusion. Dyspnea can also indicate transfusion
related acute lung injury to an anaphylactic
A. Nasuea response, which also causes wheezing, chest
B. Hypothermia tightness, cyanosis, and low BP
C. Dyspnea
D. Bradycardia
7. A nurse is assessing a client who has lung C Altered taste sensations
cancer and is undergoing radiation ther- Altered taste is a result of the release of
apy to the chest. Which of the following metabolites by dead cells
indicates an adverse effect of the thera-
py
A. Hair loss on the scalp
B. Sweating at the treatment site
C. Altered taste sensations
D. Intolerance to cold
8. A nurse is preparing to administer a A, D, E
unit of packed RBCs to a client who has A, complete assessment prior to transfusion
anemia. Which of the following actions
should the nurse plan to take (select all D, verify identification, blood compatibility, and
that apply) expiration of product with second nurse
A. Obtain pre-transfusion temperature E, the nurse should use a large bore needle to
B. Prime the IV tubing with lactated transfuse the PRBCs to reduce the risk of cell
Ringer's hemolysis and obstruction of flow
C. Instruct an assistive personnel to mon-
itor the client during the transfusion
