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 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 following statements should the nurse use to assess how the client is coping with this change in their body image? a. “Tell me how the changes to your leg make you feel.” 12. A nurse is teaching a client how to administer a medication using an inhaler with a spacer. Which of the following instructions should the nurse include? a. “Shake the inhaler vigorously prior to use.” i. Thoroughly shake the inhaler to disperse the medication because the medication in the inhaler can separate easily 13. A nurse in an endoscopy clinic is providing teaching to a client who is to under go a colonoscopy for colon cancer screening. Which of the following information should the nurse provide? a. “You will need someone to drive you home after your procedure?” i. Do not drive for 12-18 hours following the procedure, because during a colonoscopy, the patient receives moderate sedation 14. A nurse is monitoring a client who is receiving moderate sedation with midazolam. Which of the following findings requires immediate intervention by the nurse? a. No response to verbal stimuli i. Using urgent vs non-urgent approach, this is the priority; during moderate sedation, the patient should be able to provide a response to questions and commands. No response to verbal stimuli can indicate a loss of consciousness or over sedation. 15. A nurse is reviewing the laboratory findings for a client who has heart failure and is taking furosemide. The nurse should identify which of the following findings as an adverse effect of the medication? a. Potassium 3.2 mEq/L i. Loop diureticsremove excessive extracellular fluid through the kidneys, causing an increased excretion of potassium; monitor for dysrhythmias 16. A nurse is caring for a client who is in Buck’s traction. Which of the following actions should the nurse take? SATA: ATI CAPSTONE Medical Surgical Assessment 1- LATEST correct and verified Answers- WITH EXPLANATION a. Closely monitor the neurovascular integrity; circulation can be compromised from the fracture as well as the traction device b. Monitor skin integrity at least q8hrs c. Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P’s: pain, pallor, pulselessness, pressure, paresthesia, and paralysis 17. A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer’s disease. Which of the following instructions should the nurse include in the teaching? a. Lock doorsleading to stairways i. This patient is at an increased risk for falls due to difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease 18. A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan? a. Keep the client’s room dark and quiet i. Meningitis often causes photophobia (sensitive to light) and phonophobia (sensitive to sound); reduce stimuli 19. A nurse is caring for a client who has a right subclavian central venous catheter. When reconnecting a new intravenous infusion administration set, which of the following actions should the nurse take? a. Use aseptic technique i. Aseptic = sterile; prevents central line related blood infections when disconnecting and reconnecting the new set 20. A nurse is educating an older adult client about immunizations. Which of the following immunizations should the nurse include in the recommendation for the client? a. Recombinant herpeszoster i. Herpes zoster = shingles; older adults can get either the live or recombinant herpes zoster immunization 21. A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP): Which of the following actions should the nurse take? a. Subtract the amount of irrigation solution from the indwelling urinary catheter output i. Determine an accurate urinary output by subtracting the amount of irrigation solution from the total output in the urinary drainage bag 22. A nurse is administering epinephrine IV to a client who is having an anaphylactic reaction. Which of the following findings should the nurse identify as a therapeutic response to the medication? a. Non-itchy skin wheals i. A patient in anaphylactic shock can experience intensely itchy skin with wheals or hives that can merge to form large red blotches. Epi blocks the release of histamine and decreases erythema, angioedema, and hives. This finding indicates a therapeutic response to the epinephrine. 23. A nurse is assisting in selecting foods for lunch with a client who has diverticulosis. Which of the following foods should the nurse recommend as the best source of fiber? a. ½ cup cooked navy beans ATI CAPSTONE Medical Surgical Assessment 1- LATEST correct and verified Answers- WITH EXPLANATION i. Navy beans contain 5g of fiber per ½ cup