ATI Capstone Adult Medical Surgical Assessment 2
*Inject air into NPH insulin vial
*Withdraw short-acting insulin into syrgine
*Roll NPH vial between palms of hands
*Inspect vials for contaminants
*Inject air into regular insulin vial
*Add intermediate insulin to syringe - ans*Inspect vials for contaminants
*Roll NPH vial between palms of hands
*Inject air into NPH insulin vial
*Inject air into regular insulin vial
*Withdraw short-acting insulin into syringe
*Add intermediate insulin to syringe
A nurse is preparing to administer a measles, mumps, and rubella vaccine (MMR) to an adult client. Which of the following is a
contraindication to this vaccine?
1) The possibility of pregnancy within 4 weeks
2) Client allergy to strawberries
3) Client history of genital herpes
4) The possibility of overseas travel in the next month - ans1) The possibility of pregnancy within 4 weeks
Pregnancy or the possibility of pregnancy with 4 weeks is a contraindication to the MMR vaccine
A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the
medication using the ventrogluteal site?
1) a 45 degree angle
2) a 60 degree angle
3) a 75 degree angle
4) a 90 degree angle - ans4) a 90 degree angle
IM injections should be administered at a 90 degree angle
A nurse is preparing to administer bisacodyl suppository to a client. Which of the following actions should the nurse take? Select all
that apply
*Don sterile gloves
*Lubricate index finger
*Use a rectal applicator for insertion
*Position client supine with knees bent
*Insert suppository just beyond internal sphincter - ans*Lubricate index finger
*Insert suppository just beyond internal sphincter
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should
the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) -
ans0.2 mL
A nurse is providing care to a client with staphylococcus epidermidis, who is prescribed vancomycin. Identify the adverse effect
associate with the antibiotic therapy?
1) Hepatotoxicity
2) Constipation
3) Infusion reaction
4) Immunosuppression - ans3) Infusion reaction
Red Man Syndrome or an infusion reaction that results in rashes, flushing, tachycardia and hypotension can occur as an adverse
reaction. For this reason, vancomycin should be administered over a 60 minute period
A nurse is reviewing the medication class benzodiazepines. The nurse would use cautions when administering benzodiazepines to
which of the below clients?
1) A client with glaucoma
2) A client with renal failure
3) A client with hypertension
4) A client with insomnia - ans1) A client with glaucoma
Benzodiazepines can increase intraocular pressure due to the pupil-dilating effects of the medication
Before administering blood products, which action should be taken?
1) Assess the client's temperature
2) Document client response
3) Prime IV tubing with 0.45% sodium chloride
4) Administer epinephrine - ans1) Assess the client's temperature
, ATI Capstone Adult Medical Surgical Assessment 2
Assess the client's vital signs, obtain consent for the procedure and ensure compatibility. Prime the IV tubing with 0.9% sodium
chloride. The nurse would not document client response or administer epinephrine prior to starting the transfusion
Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?
1) Hepatoxicity
2) Wernicke's aphasia
3) Suicidal ideations
4) Diarrhea - ans1) Hepatoxicity
Hepatoxicity is an adverse effect of disulfiram
Which of the following are contraindications to salicylate acid therapy? Select all that apply
*Third trimester pregnancy
*Thrombocytopenia
*Coronary artery disease
*Adolescents with chickenpox
*Deep vein thrombosis - ans*Third trimester pregnancy
*Throbocytopenia
*Adolescents with chickenpox
Salicylate Acid Therapy Contraindications:
Salicylate acid is a category D agent and should not be administered to pregnant clients.
Salicylate acid is contraindicated in clients with bleeding disorders and thrombocytopenia.
Salicylate acid should not be given to children or adolescents with fever or recent chickenpox due to the risk of Reye's syndrome.
The therapy is used for the following types of clients:
Salicylate acid inhibits platelet aggregation and is often used in the treatment and prevention of thrombosis. Salicylate acid is
commonly prescribed to clients with coronary artery disease to prevent thrombus formation
A nurse enters a client's room and finds the client on the floor experiencing a seizure. Which of the following actions should the
nurse take? - ANSPosition the client on their side.
The nurse should position the client on their side. This assists the client's airway to remain open and can prevent aspiration if the
client has emesis or secretions in their mouth.
A nurse is assessing a client who has enlarged lymph nodes. In which of the following locations should the nurse palpate to locate
the postauricular nodes? - ANSOver the mastoid
The nurse should palpate over the mastoid or behind the ear to assess the postauricular nodes. The detection of an enlarged or
tender lymph node can indicate the presence of an infection or a malignancy and should be reported to the provider.
A nurse is assessing a client who has multiple sclerosis. Which of the following assessments is the nurse's priority? - ANSAbility to
swallow
The greatest risk to the client is aspiration due to dysphagia. Therefore, the nurse's priority assessment is the client's ability to
swallow.
A nurse is assisting a client to ambulate to the bathroom when the client begins to fall. Which of the following actions should the
nurse take? - ANSPlace one foot in front of the other while spreading the feet apart.
The nurse should place one foot in front of the other while spreading the feet farther apart to widen their own base of support. Then
the nurse should lower the client to the floor as smoothly as possible. This will assist with supporting the client's weight and help to
prevent injury to the nurse.
A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment
is present in the client's room? - ANSAn obturator
The nurse should ensure that a client who has a tracheostomy has an obturator at their bedside. If the tracheostomy is dislodged,
an obturator is used to reinsert the outer cannula of the tracheostomy. The nurse should also ensure that a spare tracheostomy of
the client's size, as well as a tracheostomy of one size smaller, supplemental humidified air or oxygen, and suction equipment are at
the client's bedside to ensure safe client care.
A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates
that the nurse should modify the client's plan of care? - ANSReports pain as a 5 on a scale of 0 to 10
*Inject air into NPH insulin vial
*Withdraw short-acting insulin into syrgine
*Roll NPH vial between palms of hands
*Inspect vials for contaminants
*Inject air into regular insulin vial
*Add intermediate insulin to syringe - ans*Inspect vials for contaminants
*Roll NPH vial between palms of hands
*Inject air into NPH insulin vial
*Inject air into regular insulin vial
*Withdraw short-acting insulin into syringe
*Add intermediate insulin to syringe
A nurse is preparing to administer a measles, mumps, and rubella vaccine (MMR) to an adult client. Which of the following is a
contraindication to this vaccine?
1) The possibility of pregnancy within 4 weeks
2) Client allergy to strawberries
3) Client history of genital herpes
4) The possibility of overseas travel in the next month - ans1) The possibility of pregnancy within 4 weeks
Pregnancy or the possibility of pregnancy with 4 weeks is a contraindication to the MMR vaccine
A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the
medication using the ventrogluteal site?
1) a 45 degree angle
2) a 60 degree angle
3) a 75 degree angle
4) a 90 degree angle - ans4) a 90 degree angle
IM injections should be administered at a 90 degree angle
A nurse is preparing to administer bisacodyl suppository to a client. Which of the following actions should the nurse take? Select all
that apply
*Don sterile gloves
*Lubricate index finger
*Use a rectal applicator for insertion
*Position client supine with knees bent
*Insert suppository just beyond internal sphincter - ans*Lubricate index finger
*Insert suppository just beyond internal sphincter
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should
the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) -
ans0.2 mL
A nurse is providing care to a client with staphylococcus epidermidis, who is prescribed vancomycin. Identify the adverse effect
associate with the antibiotic therapy?
1) Hepatotoxicity
2) Constipation
3) Infusion reaction
4) Immunosuppression - ans3) Infusion reaction
Red Man Syndrome or an infusion reaction that results in rashes, flushing, tachycardia and hypotension can occur as an adverse
reaction. For this reason, vancomycin should be administered over a 60 minute period
A nurse is reviewing the medication class benzodiazepines. The nurse would use cautions when administering benzodiazepines to
which of the below clients?
1) A client with glaucoma
2) A client with renal failure
3) A client with hypertension
4) A client with insomnia - ans1) A client with glaucoma
Benzodiazepines can increase intraocular pressure due to the pupil-dilating effects of the medication
Before administering blood products, which action should be taken?
1) Assess the client's temperature
2) Document client response
3) Prime IV tubing with 0.45% sodium chloride
4) Administer epinephrine - ans1) Assess the client's temperature
, ATI Capstone Adult Medical Surgical Assessment 2
Assess the client's vital signs, obtain consent for the procedure and ensure compatibility. Prime the IV tubing with 0.9% sodium
chloride. The nurse would not document client response or administer epinephrine prior to starting the transfusion
Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?
1) Hepatoxicity
2) Wernicke's aphasia
3) Suicidal ideations
4) Diarrhea - ans1) Hepatoxicity
Hepatoxicity is an adverse effect of disulfiram
Which of the following are contraindications to salicylate acid therapy? Select all that apply
*Third trimester pregnancy
*Thrombocytopenia
*Coronary artery disease
*Adolescents with chickenpox
*Deep vein thrombosis - ans*Third trimester pregnancy
*Throbocytopenia
*Adolescents with chickenpox
Salicylate Acid Therapy Contraindications:
Salicylate acid is a category D agent and should not be administered to pregnant clients.
Salicylate acid is contraindicated in clients with bleeding disorders and thrombocytopenia.
Salicylate acid should not be given to children or adolescents with fever or recent chickenpox due to the risk of Reye's syndrome.
The therapy is used for the following types of clients:
Salicylate acid inhibits platelet aggregation and is often used in the treatment and prevention of thrombosis. Salicylate acid is
commonly prescribed to clients with coronary artery disease to prevent thrombus formation
A nurse enters a client's room and finds the client on the floor experiencing a seizure. Which of the following actions should the
nurse take? - ANSPosition the client on their side.
The nurse should position the client on their side. This assists the client's airway to remain open and can prevent aspiration if the
client has emesis or secretions in their mouth.
A nurse is assessing a client who has enlarged lymph nodes. In which of the following locations should the nurse palpate to locate
the postauricular nodes? - ANSOver the mastoid
The nurse should palpate over the mastoid or behind the ear to assess the postauricular nodes. The detection of an enlarged or
tender lymph node can indicate the presence of an infection or a malignancy and should be reported to the provider.
A nurse is assessing a client who has multiple sclerosis. Which of the following assessments is the nurse's priority? - ANSAbility to
swallow
The greatest risk to the client is aspiration due to dysphagia. Therefore, the nurse's priority assessment is the client's ability to
swallow.
A nurse is assisting a client to ambulate to the bathroom when the client begins to fall. Which of the following actions should the
nurse take? - ANSPlace one foot in front of the other while spreading the feet apart.
The nurse should place one foot in front of the other while spreading the feet farther apart to widen their own base of support. Then
the nurse should lower the client to the floor as smoothly as possible. This will assist with supporting the client's weight and help to
prevent injury to the nurse.
A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment
is present in the client's room? - ANSAn obturator
The nurse should ensure that a client who has a tracheostomy has an obturator at their bedside. If the tracheostomy is dislodged,
an obturator is used to reinsert the outer cannula of the tracheostomy. The nurse should also ensure that a spare tracheostomy of
the client's size, as well as a tracheostomy of one size smaller, supplemental humidified air or oxygen, and suction equipment are at
the client's bedside to ensure safe client care.
A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates
that the nurse should modify the client's plan of care? - ANSReports pain as a 5 on a scale of 0 to 10
