Capstone Med Surg Assessment 1 all answers correct ; latest spring

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tttt capstone med surg assessment Material
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capstone med surg assessment 1 all answers correct latest
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spring 2021
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1. A nurse is updating a plan of care after an evaluation of a client who has dysphagia.
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Which of the following interventions should the nurse include in the plan?
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a) Ask the client to tilt their head back when swallowing.
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b) Have the client sit upright for 1 hr. following meals. t t t t t t t t t




c) Administer liquids to the client using a syringe. t t t t t t t




d) Allow the client to rest for 10 min prior to eating. t t t t t t t t t t




2. A nurse is assessing the IV infusion site of a client who report pain at the site. The site is
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t red and there is warmth along the course of the vein. Which of the following actions
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t should the nurse take?
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a) Initiate a new IV line below the original insertion site. t t t t t t t t t




b) Discontinue the infusion t t




c) Raise the head of the bed t t t t t




d) Obtain a culture from the area of the insertion site. t t t t t t t t t




3. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the
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t following actions should the nurse take? t t t t t




a) Document shiny, taut skin as an expected finding. t t t t t t t




b) Perform palpitation after auscultation. t t t




c) Listen for 1 min before documenting absent bowel sounds t t t t t t t t




d) Perform auscultation immediately after the client has consumed a meal. t t t t t t t t t




4. A nurse is discussing immunity with a client who has received an immunization. The
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t nurse should identify that an immunization functions as a part of the which of the
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t following types of immunity? t t t




a) Passive immunity t

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tttt capstone med surg assessment Material
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b) Active immunity t




c) Cellular immunity t




d) Acquired immunity t




5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should
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t identify that which of the following is a risk factor that places older clients at an increased
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t risk for developing infections?
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a) Overproduction of lymphocytes t t




b) Elevated albumin levels t t




c) Lowered immune system function t t t




d) Increased body fat t t




6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the
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t following instructions should the nurse include in the teaching?
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a) Hold your breath for 6 seconds after inhaling the medication.
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b) Inhale the medication deeply for 5 seconds. t t t t t t




c) Do not shake the medication in the inhaler
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d) Hold the inhaler 3 inches away from your mouth.
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7. A nurse is performing a focused assessment on a client who has a history of COPD and is
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t experiencing dyspnea. Which of the following findings should the nurse expect?
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a) Pulse oximetry reading of 95 % t t t t t




b) Decreased depth of respirations t t t




c) Flaring of the nostrils t t t




d) Respiratory rate of 16/min t t t




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