ATI CAPSTONE Medical Surgical Assessment 1- LATEST correct and verified Answers- WITH EXPLANATION

ATI CAPSTONE Medical Surgical Assessment 1- LATEST correct and verified Answers- WITH EXPLANATION Med Surg Assessment 1 1. A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan? a. Provide the client with a means of communication i. Use electronic tablet, computer, programmable speech generating device, alphabet board, pencil and paper, etc. 2. A nurse is caring for a client who is receiving IV fluid replacement therapy for dehydration. Which of the following laboratory results indicates effectiveness of the treatment? a. Urine specific gravity 1.020 i. Within the expected range of 1.005 – 1.030 3. A nurse is monitoring the laboratory findings for a client who is postoperative following a total hip arthroplasty 6 hours ago. Which of the following values indicates that the client has an increased risk for bleeding? a. Platelets 80,000 i. Platelet range is 150,000 – 400,000 4. A nurse is admitting a client who has a cervical spinal cord injury following a motor vehicle accident. Which of the following interventions is the nurse’s priority while caring for this client? a. Assist the client with quad coughing i. The greatest risk to a client who has a cervical spinal cord injury is an obstructed airway; the priority is to ensure that the client can clear their airway. Apply abdominal pressure as the client coughs (quad coughing). 5. A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicates that the client is experiencing transfusion-associated circulatory overload? a. Dyspnea i. Dyspnea is an indication of possible transfusion-associated circulatory overload, leading to hypertension, 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. 6. A nurse is assessing a client who has lung cancer and is undergoing radiation therapy to the chest. Which of the following indicates an adverse effect of the therapy? a. Altered taste sensations i. Altered taste is a result of the release of metabolites by dead cells 7. A nurse is preparing to administer a unit of packed RBCs to a client who has anemia. Which of the following actions should the nurse plan to take? SATA: a. Obtain pre-transfusion temperature i. Complete assessment prior to transfuion b. Verify the client’s blood type with a second nurse i. Verify ID, blood compatibility, and expiration of product with second nurse c. Use a 20-gauge-IV needle for venous access i. The nurse should use a large-bore needle to transfuse the PRBCs to reduce the risk of cell hemolysis and obstruction of flow 8. A nurse is reviewing the laboratory findings for a client who is dehydrated. Which of the following BUN levels should the nurse expect? ATI CAPSTONE Medical Surgical Assessment 1- LATEST correct and verified Answers- WITH EXPLANATION a. 26 mg/dL ATI CAPSTONE Medical Surgical Assessment 1- LATEST correct and verified Answers- WITH EXPLANATION i. Normal range is 10-20, and elevated levelsindicate renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, GI bleeding, or other conditions in which blood is reabsorbed from injured tissues 9. A nurse is reviewing ECG strips forseveral clients. Which of the following images should the nurse identify as atrial fibrillation? a. Multiple irregular and variable waves at the baseline and irregular R to R waves 10. A nurse is preparing to admit a client who has a new tracheostomy from the operating room. Which of the following items is the priority for the nurse to have available in the client’s room upon admission? a. Obturator i. The obturator can be inserted in the stoma in the event of dislodgment or decannulation to maintain an airway until a trach tube can be placed. For the first 72 hoursfollowing the insertion of the trach, dislodgment or decannulation is considered an emergency. 11. A nurse is caring for a client who had a below-the-knee amputation due to a traumatic injury 2 days ago. Which of the follow